Stress Echocardiography in Valvular Heart Disease

Stress echocardiography is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms during exercise or activities of daily living. The technique is especially useful in patients with a sedentary lifestyle who are asymptomatic despite severe disease or patients with nonsevere disease with symptoms. Low-dose dobutamine is the first choice in low-flow, low-gradient suspected severe aortic stenosis with reduced ejection fraction to separate true from pseudo-severe aortic stenosis. Exercise is the test of choice since it is the most physiological and the safest. Among stress exercise modalities, a semisupine bike is recommended for obtaining Doppler data during exercise. The most frequent indications are the assessment of asymptomatic severe or symptomatic nonsevere mitral regurgitation and symptomatic low-flow, low-gradient aortic stenosis with reduced ejection fraction. Prospective large-scale and randomized outcome studies are needed to support more evidence-based, stress echo-driven treatment strategies. Ongoing stress echo studies include the comprehensive assessment of nonvalvular parameters such as left ventricular contractile reserve, diastolic function, pulmonary congestion, preload, contractile reserve, and heart rate reserve.