Background
Intervention in symptomatic patients with severe valvular heart diseases is a class I recommendation in current guidelines. However, because of the slow progression of valvular disease some patients remain subjectively asymptomatic. There is limited data on cardiac functional capacity in these patients.
Methods
This single-center, retrospective study analyzed subjectively asymptomatic patients between 2020-2025 with severe valvular heart disease. Cardiopulmonary exercise testing, objectified functional capacity, supplemented by baseline transthoracic echocardiography and NT-proBNP levels. The primary endpoint was the rate of objective cardiopulmonary impairment, defined as a peak oxygen uptake (VO2peak) < 85% of predicted. Secondary endpoints included the correlation of VO2peak with TTE and NT-proBNP parameters, evaluation of the ventilatory threshold, and subgroup analyses stratified by sex, valve entity, and guideline-based intervention criteria.
Results
A total of 120 patients were included in this study. The mean age of the cohort was 58.0 ± 1.3 years. The majority of the patients were male (79.2% male). The mean EuroSCORE II value was 0.86% ± 0.05%. The most frequently represented valvular disease was mitral regurgitation (58.8%, n=67), followed by aortic stenosis (16.7%, n=20) and aortic regurgitation (15.8%, n=19). As the primary endpoint, 65% of patients demonstrated objective cardiopulmonary impairment, with a mean VO2peak of 69.71% ± 1.3% of predicted (p < 0.001). For the secondary endpoints, impairment remained highly prevalent in patients with normal NT-proBNP levels (mean predicted VO2peak: 77.5% ± 2.37%). A reduced ventilatory threshold was observed in 35% of the patients (mean VT1 31.55% ± 5.66% of predicted value). Subgroup analyses revealed that cardiopulmonary limitations occurred significantly more often in men than in women (71.6% vs. 40.0%, p = 0.003). Furthermore, stratified by guideline criteria, objective impairment was present in 62% (n = 38) of patients with severe mitral regurgitation (92.4% primary) who did not yet meet current criteria for intervention.
Conclusion
A large proportion of subjectively asymptomatic patients with severe valvular heart disease already show objective cardiopulmonary impairment, including those with normal NT-proBNP levels or without current guideline-based criteria for intervention. Cardiopulmonary exercise testing is essential in this cohort to unmask lifestyle-compensated exercise limitations, enabling earlier, more precise risk stratification and optimal treatment timing beyond subjective symptoms.
