Three-dimensional speckle tracking analysis of left ventricular multi-directional strain in severe aortic stenosis with preserved ejection fraction

Background: Myocardial contraction fraction (MCF) is a volumetric measure of myocardial shortening independent of left ventricular size and geometry. This multicenter study investigates the usefulness of MCF for risk stratification in low-gradient severe aortic stenosis with preserved ejection fraction. Methods: We included 643 consecutive patients with low-gradient severe aortic stenosis with preserved ejection fraction in whom MCF was computed at baseline and analyzed mortality during follow-up. Results: Throughout follow-up with medical and surgical management (34.9 [16.1–65.3] months), lower MCF tertiles had higher mortality than the highest tertile. Eighty-month survival was 56±4% for MCF>41%, 41±4% for MCF 30% to 41%, and 40±4% for MCF<30% ( P <0.001). After comprehensive adjustment, mortality risk remained high for MCF 30% to 41% (adjusted hazard ratio, 1.53 [1.08–2.18]) and for MCF<30% (adjusted hazard ratio, 1.82 [1.24–2.66]) versus MCF>41%. The optimal MCF cutoff point for mortality prediction was 41%. Age, body mass index, Charlson index, peak aortic velocity, and ejection fraction were independently associated with mortality. MCF (χ 2 to improve 10.39; P =0.001), provided greater additional prognostic value over the baseline parameters than stroke volume (SV) index (χ 2 to improve 5.41; P =0.042), left ventricular mass index (χ 2 to improve 2.15; P =0.137), or global longitudinal strain (χ 2 to improve 3.67; P =0.061). MCF outperformed ejection fraction for mortality prediction. When patients were classified by SV index and MCF, mortality risk was low when SV index was ≥30 mL/m 2 and MCF>41%, higher for patients with SV index ≥30 mL/m 2 and MCF≤41% (adjusted hazard ratio, 1.47 [1.05–2.07]) and extremely high for patients with SV index <30 mL/m 2 (adjusted hazard ratio, 2.29 [1.45–3.62]). Conclusions: MCF is a valuable marker of risk in low-gradient severe aortic stenosis with preserved ejection fraction and could improve decision-making, especially in normal-flow low-gradient severe aortic stenosis with preserved ejection fraction.

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Clinical significance of energy loss index in patients with low-gradient severe aortic stenosis and preserved ejection fraction

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa010 ◽

2020 ◽

Vol 21 (6) ◽

pp. 608-615 ◽

Cited By ~ 1

Author(s):

Alexandre Altes ◽

Anne Ringle ◽

Yohann Bohbot ◽

Océane Bouchot ◽

Ludovic Appert ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Ejection Fraction ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Preserved Ejection Fraction ◽

Cardiac Mortality ◽

Cardiac Events ◽

Loss Index

Abstract Aims We hypothesized that among patients with low-gradient severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF), reclassification of AS severity as moderate by pressure recovery adjusted indexed aortic valve area (AVAi) = energy loss index (ELI), may identify a subgroup of patients with a better outcome. Methods and results Three hundred and seventy-nine patients with low-gradient AS (defined by AVAi ≤ 0.6 cm2/m2 and mean aortic pressure gradient < 40 mmHg) and preserved LVEF ≥50% were studied. Reclassification as moderate AS by ELI was defined as AVAi ≤0.6 cm2/m2 but with an ELI >0.6 cm2/m2. Cardiac events [cardiac mortality and/or need for aortic valve replacement (AVR)] during follow-up were studied. One hundred and forty-eight patients (39%) were reclassified as moderate AS by ELI. Reclassification as moderate AS was independently associated with decreased body surface area, normal flow status, decreased left ventricular mass index, and left atrial volume index (all P < 0.05). After adjustment for variables of prognostic interest, reclassification as moderate AS by ELI was associated with a considerable reduction of risk of cardiac events {adjusted hazard ratio (HR) 0.49 [95% confidence interval (CI) 0.33–0.72]; P < 0.001}, need for AVR [adjusted HR 0.52 (95% CI 0.34–0.81); P = 0.004], and cardiac mortality [adjusted HR 0.46 (95% CI 0.22–0.98); P = 0.044]. Conclusion In patients with low-gradient severe AS and preserved LVEF, calculation of ELI permits to reclassify almost 40% of patients as having moderate AS. These reclassified patients have a considerable reduction of the risk of cardiac events during follow-up. Calculation of ELI is useful for decision-making in patients with low-gradient severe AS and preserved ejection fraction.

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