Key Points
• Conclusion/Relevance: “Here we present a patient with long-standing asymptomatic AR [aortic regurgitation] who did not meet the current guideline criteria for surgical intervention but demonstrated LV systolic dysfunction during exercise echocardiography, prompting referral for AVR [aortic valve replacement]. This case highlights the capacity of stress echocardiography to evaluate contractile reserve (CR) and uncover subclinical LV systolic dysfunction due to decompensated AR and identify patients who might benefit from earlier intervention.”
• In this case, a 63-year-old man with a medical history of hypertension and hyperlipidemia presented to the cardiac valve clinic for assessment of asymptomatic AR, which was an incidental observation on a screening echocardiogram performed to evaluate a heart murmur.
• In this asymptomatic patient with hemodynamically significant AR who did not rise to the level of criteria for surgery, exercise echocardiography exhibited subclinical LV systolic dysfunction. The result was a delay in the necessary valve replacement. The authors noted that poor CR on stress echocardiography in patients with severe AR serves as a marker of early decompensation that remains to be elucidated by the resting echocardiographic indices promoted by current guidelines. This presentation could be an indication for AVR to prevent irreversible ventricular remodeling.
• “Conservative management is appropriate for the majority of asymptomatic patients with chronic severe AR. However, the transition from the compensated to the early decompensated stage in severe AR may represent an optimal window for surgical intervention, albeit one that is narrow and challenging to detect. Routine stress echocardiography may identify subclinical LV systolic dysfunction in patients with severe AR who may benefit from AVR but are not presently captured by guideline-based indications,” wrote the authors.
• Conclusion/Relevance: “Here we present a patient with long-standing asymptomatic AR [aortic regurgitation] who did not meet the current guideline criteria for surgical intervention but demonstrated LV systolic dysfunction during exercise echocardiography, prompting referral for AVR [aortic valve replacement]. This case highlights the capacity of stress echocardiography to evaluate contractile reserve (CR) and uncover subclinical LV systolic dysfunction due to decompensated AR and identify patients who might benefit from earlier intervention.”
• In this case, a 63-year-old man with a medical history of hypertension and hyperlipidemia presented to the cardiac valve clinic for assessment of asymptomatic AR, which was an incidental observation on a screening echocardiogram performed to evaluate a heart murmur.
• In this asymptomatic patient with hemodynamically significant AR who did not rise to the level of criteria for surgery, exercise echocardiography exhibited subclinical LV systolic dysfunction. The result was a delay in the necessary valve replacement. The authors noted that poor CR on stress echocardiography in patients with severe AR serves as a marker of early decompensation that remains to be elucidated by the resting echocardiographic indices promoted by current guidelines. This presentation could be an indication for AVR to prevent irreversible ventricular remodeling.
• “Conservative management is appropriate for the majority of asymptomatic patients with chronic severe AR. However, the transition from the compensated to the early decompensated stage in severe AR may represent an optimal window for surgical intervention, albeit one that is narrow and challenging to detect. Routine stress echocardiography may identify subclinical LV systolic dysfunction in patients with severe AR who may benefit from AVR but are not presently captured by guideline-based indications,” wrote the authors.