Author + information
- David Messika-Zeitoun, MD, PhD∗ ()
- ↵∗Cardiovascular division, Bichat Hospital, 46 rue Henri Huchard, 75018 Paris, France
We thank Prof. Lancellotti and colleagues for their interest in our work (1) and for their comments, although questioning our ability to perform proper exercise echocardiography. Several of their comments, however, are no longer valid as, unfortunately, we made an error in the y-axis of Figure 2B during the art production, which we have now corrected (Figure 1). Nevertheless, we would like to take the opportunity in this letter to emphasize several points:
• First, Prof. Lancellotti and colleagues seemed to somewhat minimize the finding that 24% of patients considered as asymptomatic had a positive exercise test. A positive exercise test is a symptom’s equivalent and a Level I recommendation for intervention. The exact percentage may vary according to the populations selected to undergo an exercise test, but our results strongly reinforce the importance of further use of exercise testing in asymptomatic patients with aortic stenosis (AS). Fifteen years ago, the Euro Heart Survey (2) had shown that exercise testing was underused. Future prospective registries and surveys will address whether or not we have made any improvement.
• Second, we indeed enrolled 148 patients during a 10-year period, but 91 were enrolled during the last 5 years. These 148 patients were selected among 1,152 patients (approximately 90% for the evaluation of valvular heart diseases) who underwent exercise echocardiography during the same period, which underlines our expertise in this field and the careful selection of patients. Furthermore, our sample size compared well to the published reports, in particular the 2 papers of the group from Liege (n = 66 and n = 105, respectively) (3,4). Finally, patients with moderate AS only represented a minority of our population, and 80% presented with severe AS.
• Third, as mentioned by Prof. Lancellotti and colleagues, patients with a positive (abnormal) exercise test presented with greater baseline AS severity and more severe mean pressure gradient increase during exercise. A main strength of our study was to exclude these patients from the evaluation of the additional prognostic value of exercise echocardiography above exercise testing. Such differential analysis was not performed by the Liege group, and this is a potential explanation for our different findings. Changes in mean gradient and systolic pulmonary hypertension during exercise were analyzed separately, and none of them provided prognostic information.
• Fourth, Prof. Lancellotti and colleagues were right to mention that an increase in mean pressure gradient of 120 mm hg was uncommon. We again apologize, and we have now corrected Figure 2B (Figure 1). Although the y-axis was wrong, the numbers in the text, tables, and statistics were all correct.
Finally, we would like to conclude that science is doubt, questioning, and replication. We are not claiming that we have the truth, but our results are what they are, and our study has indeed limitations. Thus, we would strongly encourage Prof. Lancellotti and colleagues to update the results they have published more than 10 years ago because they have probably the largest worldwide experience. More importantly, in regard to the limited available data and their discordance, a true prospective multicenter study would be more than welcome.
Please note: Dr. Messika-Zeitoun has received honoraria/research grants from Edwards, Valtech, Abbott, Cardiowave, and Mardil.
- 2017 American College of Cardiology Foundation
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