Management decisions in aortic regurgitation: has the time for exercise assessment finally arrived?

Clinical implications of exercise-induced regional wall motion abnormalities in significant aortic regurgitation

BACKGROUND

Significant aortic regurgitation (AR) is sometimes accompanied by regional wall motion abnormalities (RWMA) during exercise stress echocardiography. The aim of this study was to estimate the association between RWMA after exercise and in the presence of significant AR in patients with coronary artery disease (CAD) or volume overload and to predict the eventual need for aortic valve replacement (AVR).

METHODS AND RESULTS

We retrospectively reviewed 182 patients with significant AR who underwent exercise echocardiography. In addition, we investigated patients with AR who underwent coronary angiography (CAG) or coronary computed tomography angiography (CCTA) and were diagnosed with CAD. The presence of RWMA after exercise was defined as newly developed RWMA after exercise and included all changes in wall motion. Patients were divided into two groups according to the presence of RWMA after exercise: the RWMA group (n = 42) and non-RWMA group (n = 140). In the RWMA group, 31 patients (73.8%) underwent coronary artery evaluation by CAG or CCTA. Only two patients in the RWMA group were diagnosed with current CAD and underwent percutaneous coronary intervention. Patients with RWMA were older (61.6 ± 10.8 vs 52.0 ± 13.7 years, P < .001), had more severe AR (54.8% vs 32.9%), and underwent AVR more frequently (40.5% vs 14.3%, P = .001) than patients without RWMA. METs (odds ratio [OR], 0.796; P = .019), difference between rest and postexercise left ventricular end-diastolic volume (OR, 0.967; P = .001), and the difference between pre- and postexercise left ventricular end-systolic volume (OR, 1.113; P < .001) were identified as independent factors associated with RWMA after exercise according to multivariable logistic regression analysis. The majority of wall motion changes were seen in the lateral and inferior segments, and the locations of wall motion changes were relatively consistent with the direction of the AR jet. The relationship between RWMA after exercise and time to AVR was investigated by simple linear regression (hazard ratio [HR], 3.402; P < .001). After adjusting for baseline parameters of diastolic blood pressure, left ventricular end-systolic dimension (LVESD), aorta size, deceleration time, and METs, the presence of RWMA after exercise was not predictive of time to AVR (HR, 1.106; P = .81). On the other hand, without forcible entry of RWMA after exercise, LVESD (HR, 1.119; P < .001) and METs (HR, 0.828; P = .006) independently predicted the eventual need for AVR as an outcome.

CONCLUSION

The degree of change in wall motion from rest to exercise in those with significant AR was not correlated with CAD, but was correlated with the severity of volume overload and exercise-induced preload changes, as well as the direction of the AR jet. In addition, RWMA after exercise had no role in predicting the need for AVR.