Stress echocardiography beyond coronary artery disease

Doppler echocardiography has become the major diagnostic tool of evaluation of valvular heart disease and the cardiomyopathies because of its ability to provide valuable haemodynamic information accurately and non-invasively. It is therefore ideally suited for haemodynamic stress testing in these patients. In aortic stenosis, dobutamine echocardiography can distinguish severe from non-severe stenosis in patients with depressed left ventricular function, low transvalvular gradients, and a relatively small (flow-related) valve area at baseline. Patients with non-severe aortic stenosis increase cardiac output and valve area with dobutamine infusion while the transvalvular gradient does not change significantly. In severe aortic stenosis, the pressure gradient increases significantly with stroke volume, but valve area does not. In patients who fail to increase stroke volume (absent contractile reserve) and therefore do not show a change in haemodynamics, the severity of the lesion is 'indeterminate'; these patients are characterized by a very poor prognosis. In mitral stenosis, patients can be identified who increase valve area during exercise, which is the fundamental mechanism by which stroke volume can be increased in mitral stenosis. The increase in pulmonary artery pressure during exercise (assessed from tricuspid regurgitant signal) can be dramatically different in patients with comparable resting haemodynamics; therefore exercise echocardiography provides information which cannot be obtained from resting measurements alone and can help to guide medical and surgical therapy. Whether stress echocardiography may be similarly helpful in patients with regurgitant lesions is still a subject of investigation. Exercise Doppler echocardiographic studies following aortic valve replacement (small valves) can identify impairment of systolic and diastolic function indicative of 'valve prosthesis-patient mismatch'. In hypertrophic cardiomyopathy the dynamics of outflow obstruction can be assessed following exercise or pharmacological intervention. In dilative cardiomyopathy, contractile reserve can be assessed by dobutamine echocardiography which may help in evaluating prognosis, guiding heart failure therapy, and monitoring therapy with cardiotoxic chemotherapeutic agents.