Applications of Stress Echocardiography in Mitral Valve Disease

Abstract

Although stress echocardiography is primarily used to exclude inducible myocardial ischemia, it also has several useful applications related to mitral valve functional assessment. Its main role relates to assessment of contractile reserve, which can be used to optimally time mitral valve surgery in the setting of significant mitral regurgitation (MR). Clinically, stress echocardiography is most often used in the setting of myxomatous mitral valve prolapse with severe regurgitation but an absence of symptoms. Exercise stress echocardiography allows physicians to assess the patient’s exercise capacity, investigate for exercise-induced pulmonary hypertension, and perhaps most importantly, assess the left ventricle’s response to exercise. Unmasking of impaired functional capacity, inducible pulmonary hypertension, precipitation of atrial arrhythmias, worsening of MR severity, or failure of augmentation in left ventricular systolic function with exercise all may suggest that the patient will benefit from mitral valve surgery. Ideally, this surgery should involve mitral valve repair, so structural information regarding leaflet morphology or thickening, subvalvular apparatus, and the degree of calcification are important observations to include for preoperative planning.

Keywords

Stress Contractile reserve Mitral regurgitation Exercise capacity 

Supplementary material

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Video 12.1 Parasternal long-axis end-systolic image at rest, demonstrating posterior mitral valve leaflet prolapse (AVI 1240 kb)
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Video 12.2 Parasternal long-axis end-systolic image at peak exercise. Note the decreased left ventricular cavity size (AVI 892 kb)
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Video 12.3 Parasternal short-axis end-systolic image at rest (AVI 1241 kb)
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Video 12.4 Parasternal short-axis end-systolic image at peak exercise. Note the decreased left ventricular cavity size (AVI 932 kb)
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Video 12.5 Apical two-chamber end-systolic image at rest (AVI 1273 kb)
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Video 12.6 Apical two-chamber end-systolic image at peak exercise. Note the decreased left ventricular cavity size (AVI 849 kb)
Video 12.7

Apical four-chamber view with color Doppler demonstrating moderate (2+) mitral regurgitation at baseline (heart rate 62 bpm) (MOV 454 kb)

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Video 12.8 Parasternal stress echocardiographic images before exercise (left images) and after exercise (right images). The images at the top show the long-axis view and the bottom images show the short-axis view at the level of the mid left ventricle. The left ventricular cavity increases with exercise stress, consistent with impaired contractile reserve (AVI 1799 kb)
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Video 12.9 Apical four-chamber (top) and two-chamber (bottom) stress echocardiographic images before exercise (left images) and after exercise (right images). The left ventricular cavity size increases with exercise stress, consistent with impaired contractile reserve (AVI 1904 kb)
Video 12.10

Apical four-chamber view with color Doppler demonstrating severe (4+) mitral regurgitation in the early recovery phase even though the heart rate had nearly returned to the baseline of 68 bpm (MOV 432 kb)

Video 12.11

Parasternal long-axis view at rest, with color Doppler imaging demonstrating a repaired mitral valve with an annuloplasty ring and trivial valvular mitral regurgitation (AVI 1849 kb)

Video 12.12

(a) Parasternal long-axis view before exercise (AVI 8020 kb)

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Video 12.12 (b) The same view after exercise, demonstrating a decrease in left ventricular size with stress, indicative of preserved contractile reserve. No regional wall motion abnormalities are seen that would suggest underlying myocardial ischemia, although this exercise was at a submaximal predicted heart rate. (AVI 1331 kb)
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Video 12.13 (a) Apical four-chamber view before exercise (AVI 1344 kb)
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Video 12.13 (b) The same view after exercise, demonstrating a decrease in left ventricular size with stress, indicative of preserved contractile reserve. No regional wall motion abnormalities are seen that suggest underlying myocardial ischemia, although this exercise was at a submaximal predicted heart rate. (AVI 973 kb)
Video 12.14

(a) Color Doppler imaging of the tricuspid valve at rest demonstrates mild to moderate (1–2+) tricuspid regurgitation (AVI 2068 kb)

Video 12.14

(b) This regurgitation increases to moderately severe (3+) after exercise stress. (AVI 2169 kb)

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Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  1. 1.Department of Cardiovascular MedicineCleveland ClinicClevelandUSA

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