Exercise behavior of degenerative mitral stenosis

Stress echocardiography in valvular heart disease

Valvular heart disease (VHD) has been a significant health problem, particularly in developed countries, in relation to the aging population. Recent developments in the management of VHD require a more accurate assessment of disease severity to determine the need for transcatheter interventions or open heart surgery. Stress echocardiography is a crucial imaging modality for identifying the underlying pathology of VHD. Optimal administration of exercise or intravenous drugs may reveal hemodynamic abnormalities under stress without posing an invasive risk. Therefore, the implementation of stress echocardiography is recommended for determining interventional indications and risk stratification in mitral regurgitation and aortic stenosis. In addition, recent evidence has accumulated regarding the usefulness of stress echocardiography in various conditions including mitral stenosis, aortic regurgitation, and post-interventional VHD. Here, we summarize the current evidence and future perspectives on stress echocardiography in VHD.

Physical activity and exercise recommendations for patients with valvular heart disease

There is a paucity of studies looking at the natural history of valvular heart disease (VHD) in exercising individuals, and exercise recommendations are largely based on expert consensus. All individuals with VHD should be encouraged to avoid sedentary behaviour by engaging in at least 150 min of physical activity every week, including strength training. There are generally no exercise restrictions to individuals with mild VHD. Regurgitant lesions are better tolerated compared with stenotic lesions and as such the recommendations are more permissive for moderate-to-severe regurgitant VHD. Individuals with severe aortic regurgitation can still partake in moderate-intensity exercise provided the left ventricle (LV) and aorta are not significantly dilated and the ejection fraction (EF) remains >50%. Similarly, individuals with severe mitral regurgitation can partake in moderate-intensity exercise if the LV end-diastolic diameter <60 mm, the EF ≥60%, resting pulmonary artery pressure <50 mm Hg and there is an absence of arrhythmias on exercise testing. Conversely, individuals with severe aortic or mitral stenosis are advised to partake in low-intensity exercise. For individuals with bicuspid aortic valve, in the absence of aortopathy, the guidance for tricuspid aortic valve dysfunction applies. Mitral valve prolapse has several clinical, ECG and cardiac imaging markers of increased arrhythmic risk; and if any are present, individuals should refrain from high-intensity exercise.