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Aortic stenosis has become the most frequent type of valvular heart disease in Europe. Severe Aortic Stenosis (SAS) is defined as an aortic valve area b1 cm (or 0.6 cm/m), a mean transvalvular gradient N40 mmHg, a peak velocity N4 m/s, and permeability index b25% [1]. Some patients may have lower than expected transvalvular gradients (b40 mmHg) as a consequence of “low flow/low gradient SAS with depressed LVEF” or in the recently described “paradoxical low gradient aortic stenosis”. This survey was designed to explore practices on aortic valve stenosis, with particular interest for the management of patients with “nonclassical” aortic stenosis, for which guidelines were lacking in 2012. From June to November 2012, all graduated cardiologists of the region “Nord-Pas-de-Calais”were asked to answer a survey on SAS and received a questionnaire comprising 5 clinical scenarios of SAS. A choice of four different responses to each scenariowas proposed, i.e. surgical treatment, trans-aortic valve implantation, medical treatment with follow up or complementary explorations. An echocardiography specialist was defined as a cardiologist who performed more than 25 echocardiographies a week and an aortic stenosis specialist as a practitioner who diagnosed more than 40 aortic stenosis a year. Categorial variables were compared with the Chi-squared test of Pearson. A p-value≤ 0.05 was considered for statistical significance. Analysiswas conducted using Statistical Package for Social Sciences (SPSS, v17.0) software. 313 cardiologists were surveyed. The response rate was 29.7% (93/ 313) overall. Cardiologists' mean age was 42.6 ± 11.4 years old. 36 (38.7%) of them were echocardiography specialists and 30 (32.3%) were aortic stenosis specialists. 35 (37.6%) cardiologists worked in a teaching hospital, 32 (34.4%) in a general hospital, and 26 (26%) have a nonhospital activity.

BackgroundExercise testing is indicated in the evaluation of asymptomatic patients with severe aortic stenosis. Althought, « limited breathlessness » is a subjective symptom, difficult to evaluate for physicians, but it is the corner stone of the decision process to address the patient to the surgeon. The cardiopulmonary exercise-testing might help to distinguish ‘false’ asymptomatic patients to true by showing objective alteration in aerobic capacity.MethodsFrom December 2012 to September 2013, 21 asymptomatic patients (mean age 61+/-18 years, 52% men) with aortic stenosis defined by peak aortic jet velocity > 3m/s and preserved left ventricular ejection fraction (50%) were recruited. All patients were prospectively submitted to exercise stress echocardiography, cardiopulmonary exercise-testing and measurement of plasma NT-proBNP.ResultsAll patients underwent the double exercise protocole with no complication. The average mean oxygen consumption at peak exercise (VO2peak) was 21.1+/–7.3ml/kg/min, 84+/–18% predicted value). 11 (52%) patients had unexpected poor aerobic capacity, i.e. VO2peak 85% of the predicted value had any alteration of the oxygen pulse. None of the usual markers of poor prognosis in asymptomatic patients with aortic stenosis was significally associated with low aerobic capacity.ConclusionCardiopulmonary exercise-testing could be useful to determine a group of asymptomatic patients with aortic stenosis presenting an alteration of their functionnal capacity. This alteration of the oxygen consumption was not predicted by any of the markers actually used to risk stratification, especially not by the simple exercise-test criteria or the evaluation of the limited breathlessness by the NYHA score. A prospective follow-up of theese patients is required to determine if the alteration of the aerobic capacity in this population is associated with a poor prognosis.