Exercise Testing in Mitral
Regurgitation
September 2013
Randolph P. Martin, MD, FACC, FASE, FESC
Randolph P. Martin, M.D., FACC, FASE, FESC
Disclosures
1.
2.
3.
4.
Medtronic, Inc. – Speaker
Edwards LifeSciences – Speaker
Sorin Group USA, Inc. – Speaker
Siemens Medical Solutions USA, Inc. –
Research Grant
Washington Post’s Mensa
Invitational Event
• Invited readers to take any word from the
dictionary and alter it by
• adding, subtracting, or changing one letter,
thereby giving a new definition
• The winners
Washington Post’s Mensa
Invitational Event
• Ignoranus: A person who’s both stupid
and an asshole.
• Reintarnartion: Coming back to life as a
Hillbilly
• Bozone: The substance surrounding
stupid people that stops bright ideas
from penetrating.The Bozone
layer,unfortunately,shows little signs of
breaking down in the near future
Washington Post’s Mensa
Invitational Event
4. The Dopeler Effect : The tendency of stupid
ideas to seem smarter when they come at
you rapidly.
Mitral Valve-Mitral Regurgitation
While It’s about the valve
What maybe more Important:
Affect of MR on LA sizeOccurance of AFib
Affect of MR on LV size
Affect on LV function
Affect Pulmonary Pressures
Affect RV size and function
Tricuspid Valve -Annulus
Mitral Regurgitation
• It’s not how severe YOU think it is
• It’s how severe the HEART thinks it is:
–
–
–
–
LV size & function
LA size & function (A-Fib)
RV size & function
Pulmonary pressures (Pul HPT)
Degenerative MR
• Waiting too late for surgery is denoted by:
– Presence of LV dysfunction
– Left ventricular enlargement at end systole
– Presence of Atrial-Fib
– Presence of Pulmonary Hypertension
Resting Pulmonary Hypertension
Exercise induced Pulmonary Hypertension
Intervene in Severe MR-Degenerative MR---
MY Opinion
Before Symptoms develop
Before LVEF before <65%
Before LV enlarges - before LVES is
>3.7cm
Before LAE-AF
Before Pulmonary Hypertension
develops
Timing for Surgery –especially
AsymptomaticDegenerative MR
13
Mitral Repair-Need Excellence in
Surgical Judgement and Outcomes
“Let’s just start cutting and see what happens.”
A Quote
“Avoid patient – surgeon missmatch.”
Maurice Sarano, M.D.
Not all MV Repair Surgeons are the same
just as fact that not all Penquins are the
same
Findings to Follow in Exercise Testing
in Degenerative MR
• Exercise Duration
• Cardiopulmonary Exercise Capacity (VO2 max)
• Signs/Symptoms during exercise
– DOE/ Chest Pain (+/-)
– EKG findings (+/-)
• Echo parameters @ peak or immediate
post-exercise
– LVEF (Longitudinal Strain?)
– MR Severity
– RV systolic pressures
Supino et al. AJC 2007;100:1274-1281
Prognostic Value of Exercise Tolerance
Testing in Asx Degenerative MR
Supino et al. AJC 2007;100:1274-1281
• 38 ASx pts with severe degenerative MR
• No indications for surgery at intake
• Underwent maximum treadmill stress testing
• Follow-up 7+ 3 years
• Duration (time) on TMST compared with
end points reached over follow-up
Prognostic Value of Exercise Tolerance
Testing in Asx Degenerative MR
Supino et al. AJC 2007;100:1274-1281
• End points are:
– A-Fib
– LVEF < 60%
– LVES > 45 mm
Event;
SD
CHF
AF
LVEF<60
LVES>45
Annual Event rate=4.6%
Annual event rate=23%
Ex >15Min
Ex <15 min
Supino et al. AJC 2007;100:1274-1281
Prognostic Value of ET in ASx
Degenerative MR
Supino et al. AJC 2007
• Authors conclude:
– Decreased exercise tolerance
in ASx Pts. with significant MR
due to:
– Development of Pul HPT
– Development of RV dysfunction
Cardiopulmonary Exercise Testing in
Asx Degenerative MR
Messika-Zetouin et al. JACC 2006;47:2521-2527
• 134 ASx pt. with significant degenerative MR
• Underwent Cardiopulmonary Testing
•
(Modified Bruce – 2-minute stages)
Followed for 3-years for development of
end points
– Death
– HF
– New significant Symptoms
– New atrial arrhythmias
Cardiopulmonary Exercise Testing in
Asx Degenerative MR
Messika-Zetouin et al. JACC 2006;47:2521-2527
Findings:
1. ↓ Functional capacity found in 20-25%
patients who were clinically ASx
2. ↓ Functional capacity on CP ET is
marker for:
–Risk of developing clinical events
–Need for surgery (possible)
Clinical events;
SD
CHF
AF
New Sx
Indication for
Surgery
Messika-Zetouin et al. JACC 2006;47:2521-2527
Cardiopulmonary Exercise Testing in
ASx Degenerative MR
Messika-Zetouin et al. JACC 2006;47:2521-2527
8. Need for surgical intervention:
– More frequent in those with reduced
functional capacity (66%) than those
with normal functional capacity (29%)
Exercise
–Pulmonary Hypertension in
Exercise–Pulmonary
Asymptomatic Degenerative Mitral
Regurgitation
Magne et al; Circ 2010;122:33
-41
2010;122:33-41
Exercise Pulmonary Hypertension in
ASx Degenerative MR – Magne et al. Circ 2010
• 78 Patients with at least moderate MR
(ERO > 20 mm2) and preserved LV
systolic function (LVES < 45 mmHg &
LVEF > 60%)
• All patients underwent Bicycle Exercise Test
• Patients followed at 12-month interval
• Results
Exercise Pulmonary Hypertension in
ASx Degenerative MR – Magne et al. Circ 2010
•Resting PHT or Exercise-induced PHT
associated with marked reduction in 2
year Sx free survival
•46% of ASx patients with moderate or
severe MR developed Exercise PHT
• Exercise PHT more accurate than Resting
PHT for predicting occurrence of
Symptoms and Events
Exercise Stress Echo in
Degenerative MR
• Magne et al found that exercise SPAP of
> 56 mm was the best predictor of
occurrence of symptoms during followup – not SPAP of > 60 mm
Exercise Pulmonary Hypertension in
ASx Degenerative MR – Magne et al. Circ 2010
• Exercise Echo useful for unmasking latent
LV dysfunction
• Exercise Echo can reveal an  in MR severity
• Exercise-induced Pulmonary Hypertension
( > 56-60 mmHg) denotes population who
should be considered for operative
intervention
Findings to Follow in Exercise Testing
in Degenerative MR
• Exercise Duration
– Longer is better
• Cardiopulmonary Exercise Capacity (VO2 max)
• Signs/Symptoms during exercise
– DOE/ Chest Pain (+/-)
– EKG findings (+/-)
• Echo parameters @ peak or immediate
post-exercise
– LVEF (Longitudinal Strain?)
– MR Severity
– RV systolic pressures
WP
79 yr old Very Active Male
“newly Diagnosed MR murmur”
Rest and Stress Echo
Completed 7min –Stage 3 BruceNo Ischemic Symptoms-No unusal DOE;
2008-11-26
PRE
Resting TR -3.07m/s
Resting RVSP=43mmHG
EXERCISE
Immediate Post Exercise-TR =4 m/s
Immediate Post Exercise RVSP=75 mmHg
PRE
RVSP=43mmHG
POST
RVSP=75mmHG
WP
79 yr old Very Active Male
“newly Diagnosed MR murmur”
Stress Echo Stage 3 BruceNo Ischemic Symptoms-No DOE
Exercise LVEF-80%
RVSP=75mmHG
Underwent Successful Repair
Went on African Safari 3 months later
NH
 52 yr old female Accountant
 History of “Murmur”- Louder on latest PE
 Resting Echo 4/28/12 :
Flail Post MV leaflet with “moderatelysevere” anteriorly directed MR,
LVEF=65-70,
LVED/LVES=5.1/2.8cm,
Resting RVSP=40mmhg
LAVol Index=62-67 ml/M2
Said to be Asymptomatic
LVES=2.8cm
Resting RVSP=40mmHG
LA Vol Index=62 ml/M2
NH
 Exercise Echo 5/31/12
 7min 13 sec –Stage III Bruce-
Peak HR=162 {96% APMHR}
Marked DOE
 Immediate Post Exercise Echo;
Normal rise in LVEF to 80-85%
MR dramatic increase
RVSP rose from 40mmHR at rest to
78-83 mmHG immediate post exercise
TR=4.3m/s
RVSP=78-83mmHG
5min Post
TR=3.7
RVSP=59-64
TR=3.9m/s
RVSP=66-71
Rest RVSP=40mmHG
Post RVSP=83mmHG
 MM 8/2/04
 53 yr M-Executive
 Asx-runs 5 miles a day
 What All do you see
LVED=5.6cm
LVES=3.4CM
RVSP=24-29mmHG
MM
 TEE 8/2/04
 MM 8/3/04
 53 yr M-Executive
 Flail P2
 Says He is Asx-Runs 5 miles 3 times a week
 Exercise Echo= 12 min on Bruce-Stage IV-13-
15 METS
No Sx-No EKG Abn
LVEF Increased 75 %
RVSP-Rest 25mmHG
- Exercise 36mmHG
MM
 Excellent Exercise Capacity
 Totally Asymptomatic
 Elected to follow with repeat TTE and
Exercise Echoes
MM
LVED
LVES
2/22/11
5.4
3.2-3.4
65-70%
4+
2/16/10
5.6-5.8
3.2-3.5
60-65%
11/13/08
5.2
(5.8 mm)
EF
MR-ERO
RF
RVSP
AoS Asc
R:38
Ex: 59
3.6
3-4+
R:28
E:52
3.6
65%
4+
ERO = .4
R:31-36
EX:46
3.6
3.35
65%
3-4+
R: 32
Ex:42
3.6
3+/ERO=.3
VC-.54
R:30
Ex:38
3.7
3.0
(3.4 mm)
11/09/07
5.4-5.25
09/15/06
5.3-5.7
3.3-3.6
65%
08/03/04
5.6-5.7
3.3-3.5c
65%
4+
52
R: 25
Ex:36
3.8
MM-2/07/12





MM 2/07/12
61 yr M-Executive
Flail P2
Says He is Asymptomatic
Runs 5 miles 3 times a week-Does Boot camp 4x a
week
 Exercise Echo= 15 min on Bruce-Stage V15-17 METS
No Sx-No EKG Abn
LV EF Increased 75 %
Increase in RVSP to 65mmHG
LVED-5.5cm
LVES=3.2cm
RVSP=65mmHG
Pulmonary Artery Systolic Pressure Response to Exercise:
The Physiologic Range
Physiology:
Pulmonary resistance
LV filling pressure
Cardiac Output
Bossone E. et al. J Am Coll Cardiol.1999; 33:1662-6.
LVED
LVES
EF
MR-ERO
RF
2/19/13
5.5-5.6
3.3
65-70%
4+
Rest: 34
Ex: 61-64
7/30/12
5.3-5.5
3.2
65-70%
4+
Rest: 36
Ex: 65
Rest: 36
Ex: 65
RVSP
2/07/12
5.5-5.7
3.2-3.5
65%
4+
2/22/11
5.4
3.2-3.4
65-70%
4+
R:38
Ex: 59
2/16/10
5.6-5.8
3.2-3.5
60-65%
3-4+
R:28
Ex:52
65%
4+
ERO = .4
R:31-36
EX:46
3.35
65%
3-4+
R: 32
Ex:42
3+/ERO=.3
VC-.54
R:30
Ex:38
R: 25
Ex:36
11/13/08
5.2
(5.8 mm)
3.0
(3.4 mm)
11/09/07
5.4-5.25
09/15/06
5.3-5.7
3.3-3.6
65%
08/03/04
5.6-5.7
3.3-3.5c
65%
4+
52
DB
 67 yro very active Executive
 Diagnosed with signficant MR from flail A3-A2
DB-TEE 7/15/11
DB-TEE 7/15/11
DB-TEE 7/15/11
DB-TEE 7/15/11
DB
 MV Repair 11/29/2011
 Barlows deformity with exceesive tissue and
RCT to A3-A2
 3 chordal transfer to A1-2-3 and 3 Gore tex
chords to adjust height of Anterior leaflet
 36 Physio Ring
 28 Tri Ad TV ring
 “Minimal MR’ on hospital discharge Echo
12/06/11
DB- July 2013
 “New Systolic Mumur” Heard
 Patient totally Asymptomatic-Runs daily
DB-Exer Echo 7/15/13
DB-Mean Resting MV Grad=3mmHg
DB-Rest MR-choose this or next
one
DB-Resting Echo
DB-Rest-7/15/13
DB-TV-whiff TR
7/15/13
DB-Rest TV grad- No TR
DB Full Bruce Exercise TMST
 Max 10:28 –Stage 4 Bruce- 13 Mets
 Max HR=130—85%APMHR
 Max BP 188/75
 No Symptoms or Signs
DB-Immediate Post exer
DB-1 min post
DB-2 min Post
DB- Mean MV grad 1-2 min Post
9 mmHG
DB- TV Post exer
no significant TR to measure
DB Full Bruce Exercise TMST
 Max 10:28 –Stage 4 Bruce- 13 Mets
 Max HR=130—85%APMHR
 Max BP 188/75
 No Symptoms or Signs
 Mean MV Gradient-3
 Rest MV gradient-9mmHG