Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, University of Liège, Liège, Belgium.
Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, University of Liège, Liège, Belgium.
JACC Cardiovasc Imaging. 2014 Feb;7(2):188-99. doi: 10.1016/j.jcmg.2013.08.011.
The management and the clinical decision making in asymptomatic patients with aortic stenosis are challenging. An "aggressive" management, including early aortic valve replacement, is debated in these patients. However, the optimal timing for surgery remains controversial due to the lack of prospective data on the determinants of aortic stenosis progression, multicenter studies on risk stratification, and randomized studies on patient management. Exercise stress testing with or without imaging is strictly contraindicated in symptomatic patients with severe aortic stenosis. Exercise stress test is now recommended by current guidelines in asymptomatic patients and may provide incremental prognostic value. Indeed, the development of symptoms during exercise or an abnormal blood pressure response are associated with poor outcome and should be considered as an indication for surgery, as suggested by the most recently updated European Society of Cardiology 2012 guidelines. Exercise stress echocardiography may also improve the risk stratification and identify asymptomatic patients at higher risk of a cardiac event. When the test is combined with imaging, echocardiography during exercise should be recommended rather than post-exercise echocardiography. During exercise, an increase >18 to 20 mm Hg in mean pressure gradient, absence of improvement in left ventricular ejection fraction (i.e., absence of contractile reserve), and/or a systolic pulmonary arterial pressure >60 mm Hg (i.e., exercise pulmonary hypertension) are suggestive signs of advanced stages of the disease and impaired prognosis. Hence, exercise stress test may identify resting asymptomatic patients who develop exercise abnormalities and in whom surgery is recommended according to current guidelines. Exercise stress echocardiography may further unmask a subset of asymptomatic patients (i.e., without exercise stress test abnormalities) who are at high risk of reduced cardiac event free survival. In these patients, early surgery could be beneficial, whereas regular follow-up seems more appropriate in patients without echocardiographic abnormalities during exercise.
对于无症状主动脉瓣狭窄患者的管理和临床决策具有挑战性。在这些患者中，包括早期主动脉瓣置换术在内的“积极”治疗方法存在争议。然而，由于缺乏关于主动脉瓣狭窄进展决定因素的前瞻性数据、多中心风险分层研究以及患者管理的随机研究，手术的最佳时机仍存在争议。对于严重主动脉瓣狭窄的有症状患者，运动压力测试（无论是否有影像学检查）均被严格禁止。目前的指南建议在无症状患者中进行运动压力测试，该测试可能会提供额外的预后价值。实际上，运动过程中出现症状或血压反应异常与不良预后相关，应考虑作为手术指征，这是欧洲心脏病学会 2012 年最新更新的指南所建议的。运动负荷超声心动图也可以改善风险分层，并识别出处于更高心脏事件风险的无症状患者。当该测试与影像学检查相结合时，应建议在运动期间而非运动后进行超声心动图检查。在运动过程中，如果平均压力梯度增加>18 至 20mmHg、左心室射血分数无改善（即无收缩储备）和/或收缩期肺动脉压>60mmHg（即运动性肺动脉高压），则提示疾病处于晚期且预后不良。因此，运动压力测试可识别出静息无症状患者，这些患者在运动时会出现异常，根据现行指南建议进行手术。运动负荷超声心动图可能进一步揭示一组无症状患者（即运动压力测试无异常），这些患者的心脏事件无不良生存风险较高。在这些患者中，早期手术可能有益，而在运动期间无超声心动图异常的患者中，定期随访似乎更为合适。
