Cardiopulmonary exercise testing led to a change in the management plan in 24% of patients with severe asymptomatic valvular heart disease, predominantly shifting toward interventional approaches.
Observational (n=70)
Does cardiopulmonary exercise testing (CPET) influence clinical management in patients with severe asymptomatic valvular heart disease?
CPET provides objective physiological data that alters clinical management in nearly one-quarter of patients with severe asymptomatic valvular heart disease, particularly by supporting earlier intervention in aortic stenosis.
Abstract Background Cardiopulmonary exercise testing (CPET) provides objective assessment of functional capacity, yet remains underused despite potential to guide intervention timing when clinical-imaging discordance exists in valvular heart disease (VHD). Purpose Following the 2025 ESC Guidelines for Management of VHD, which support earlier intervention for severe aortic stenosis, we evaluated whether CPET influences management beyond echocardiographic assessment in severe asymptomatic VHD. Methods We performed a prospective descriptive analysis of 70 consecutive patients with severe asymptomatic VHD undergoing CPET (January-September 2025). Trained cardiologists classified tests as clinically normal/abnormal. Pathological VO2 was defined as peak VO2 ≤80% predicted. VE/VCO2 slope differences between groups were assessed. Results The cohort included 14 patients with mitral regurgitation (MR), 4 with aortic regurgitation (AR), 47 with aortic stenosis (AS; mean aortic valve gradient 46.2±11.4mmHg, aortic valve area 0.81±0.2cm²), 4 with tricuspid regurgitation (TR), and 1 with mitral stenosis (MS). The median age was 70.0 years (Q1 62.5, Q3 76.8), and 41% were female. Overall, CPET results were clinically normal in 64% of patients, abnormal in 32%, and non-conclusive in 4%. Patients with clinically normal tests had significantly lower VE/VCO2 slope (31.0 ± 5.3 %) compared with those with clinically abnormal tests (36.0 ± 5.9 %; p 0.001). Among regurgitant lesions, functional performance was largely preserved: 93% of MR and 100% of AR patients had clinically normal CPETs, with no pathological VO2 values. In contrast, functional capacity was reduced in TR, where only 50% had clinically normal CPETs and 75% displayed a pathological VO2. Among stenotic lesions, AS patients, representing two-thirds of the cohort, showed the lowest functional capacity: 55% had clinically normal CPETs, while 38% were abnormal. 57% of AS patients had a pathological VO2 ≤80% of predicted. The single MS patients had a clinically abnormal CPET but displayed a normal VO2. After CPET, the management plan changed in 24% of patients, predominantly shifting from conservative to interventional approaches, most notably in AS. Conclusions In this prospective case series of 70 patients with severe asymptomatic VHD, CPET provided objective physiological insight and guided intervention decisions through individualized assessment of patient performance, influencing management in nearly one in four patients. The test was particularly informative in severe AS, where it confirmed functional limitation and supported early intervention. The observed discrepancy between clinically normal CPETs and pathological VO2 values underscores the need to define which CPET parameters should serve as key pathological thresholds in this population, as some patients with apparently normal exercise responses may still demonstrate subclinical functional impairment.For image description, please refer to the figure legend and surrounding text. For image description, please refer to the figure legend and surrounding text.
Fernandez et al. (Mon,) conducted a observational in Severe asymptomatic valvular heart disease (n=70). Cardiopulmonary exercise testing (CPET) was evaluated on Change in management plan after CPET. Cardiopulmonary exercise testing led to a change in the management plan in 24% of patients with severe asymptomatic valvular heart disease, predominantly shifting toward interventional approaches.