LEFT ATRIAL PHASIC VOLUMES AND GLOBAL LONGITUDINAL STRAIN HAVE PROGNOSTIC VALUE IN PATIENTS UNDERGOING TRANSARTERIAL VALVE IMPLANTATION FOR SEVERE AORTIC STENOSIS

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Investigaciones Médicas. Cardiodiagnóstico. Buenos Aires Introduction. Left ventricle Global Longitudinal Strain(GLS) at rest has shown prognostic value in patients(pts) with severe aortic stenosis(SAS). Contractile reserve(CR) during exercise stress echo(ESE) estimated by GLS(CR-GLS) could better stratify the asymptomatic patients who could benefit from early intervention. Objective. To establish the long-term prognostic value of CR-GLS in pts with asymptomatic SAS during ESE. Secondly, to compare if the CR evaluated by ejection fraction(CR-EF) presented similar results to those of CR-GLS. Methodology. In a single center, prospective study carried out between May 2013 to Oct 2019, we enrolled 101 pts(69 ± 12 years,54 men) with asymptomatic SAS(aortic valve area < 0,6cm2/m2) and preserved EF(>55%). GLS value was considered as the average of the 16 segments, obtained from the apical views of 3, 4 and 2 chambers at rest and peak ESE. CR was considered present with stress-rest increase of >5points with EF and >2 absolute points by GLS. The pts were divided into 2 groups(G): G1:Pts with presence of CR-GLS and G2:Pts with absence of CR-GLS. Major cardiovascular event was considered to be: need for valve replacement due to the presence of symptoms, death, acute myocardial infarction and stroke. All patients were followed-up. Results. Of the 101 pts analyzed, 56pts(55.4%) were included in G1(CR-GLS) and 45pts(44.6%) in G2(no CR-GLS). The G2 patients were older(G2 72.2 ± 8.5 vs G1 66.5 ± 14.1) with lower METS(G1 5.6 ± 2 vs G2 4.2 ± 1.1,p 0.004), a higher percentage of flat blood pressure response(G1 19.6% vs. G2 37.8%,p 0.036), lower peak EF(G1 71.5%±5.8 vs G2 66.8 ± 7.9,p0.001),peak GLS(G1 -22.2%±2.8 vs G2 -18.45%±2.4 p 0.001) and lower ΔGLSstress-rest(G1 GLS 3.07 ± 0.85 vs G2 0.08 ± 1.9 p 0.003). The same behaviour with the EF response(G1 7.32 ± 2.9 vs G2 4.7 ± 5.3,p 0.024). The average follow-up was 46.6 ± 3.4 months, and events occurred in 45 patients: 12 all-cause deaths(9 cardiac), 31 valve replacement, 1 myocardial infarctions, 1 strokes. G2 pts had more events compared to G1 pts (G2 = 26 events 57.8% vs G1 = 19 events 42.2%,p < 0.01)(figure 1). The CR-EF did not separate patients with and without events. At Cox analysis, CR-GLS was the only predictor variable of major events(HR:1.97, 95% CI 1.09-3.58)p < 0.025). Conclusions In patients with asymptomatic SAS, the absence of CR-GLS during ESE identifies a group of patients with a worse prognosis and the need for aotic valve intervention. CR-GLS proved to be superior tan CR-EF. Baselin characteristic between groups Abstract Figure. Left ventricle RC-GLS and survival

Download Full-text

Incremental value of left ventricular global longitudinal strain in a newly proposed staging classification based on cardiac damage in patients with severe aortic stenosis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa220 ◽

2020 ◽

Vol 21 (11) ◽

pp. 1248-1258 ◽

Cited By ~ 1

Author(s):

E Mara Vollema ◽

Mohammed R Amanullah ◽

Edgard A Prihadi ◽

Arnold C T Ng ◽

Pieter van der Bijl ◽

...

Keyword(s):

Aortic Stenosis ◽

Prognostic Value ◽

Longitudinal Strain ◽

Severe Aortic Stenosis ◽

Global Longitudinal Strain ◽

Left Ventricular ◽

Cardiac Damage ◽

All Cause Mortality ◽

Incremental Prognostic Value ◽

Staging Classification

Abstract Aims Cardiac damage in severe aortic stenosis (AS) can be classified according to a recently proposed staging classification. The present study investigated the incremental prognostic value of left ventricular (LV) global longitudinal strain (GLS) over stages of cardiac damage in patients with severe AS. Methods and results From an ongoing registry, a total of 616 severe symptomatic AS patients with available LV GLS by speckle tracking echocardiography were selected and retrospectively analysed. Patients were categorized according to cardiac damage on echocardiography: Stage 0 (no damage), Stage 1 (LV damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (tricuspid valve or pulmonary artery vasculature damage), or Stage 4 (right ventricular damage). LV GLS was divided by quintiles and assigned to the different stages. The endpoint was all-cause mortality. Over a median follow-up of 44 [24–89] months, 234 (38%) patients died. LV GLS was associated with all-cause mortality independent of stage of cardiac damage. After incorporation of LV GLS by quintiles into the staging classification, Stages 2–4 were independently associated with outcome. LV GLS showed incremental prognostic value over clinical characteristics and stages of cardiac damage. Conclusion In this large single-centre cohort of severe AS patients, incorporation of LV GLS by quintiles in a novel proposed staging classification resulted in refinement of risk stratification by identifying patients with more advanced cardiac damage. LV GLS was shown to provide incremental prognostic value over the originally proposed staging classification.

Download Full-text

Prognostic Value of Global Longitudinal Strain in Paradoxical Low-Flow, Low-Gradient Severe Aortic Stenosis With Preserved Ejection Fraction

Circulation Journal ◽

10.1253/circj.cj-14-0726 ◽

2014 ◽

Vol 78 (11) ◽

pp. 2750-2759 ◽

Cited By ~ 33

Author(s):

Kimi Sato ◽

Yoshihiro Seo ◽

Tomoko Ishizu ◽

Masaaki Takeuchi ◽

Masaki Izumo ◽

...

Keyword(s):

Aortic Stenosis ◽

Ejection Fraction ◽

Prognostic Value ◽

Longitudinal Strain ◽

Severe Aortic Stenosis ◽

Global Longitudinal Strain ◽

Low Flow ◽

Preserved Ejection Fraction

Download Full-text

The Prognostic Value of Left Atrial Global Longitudinal Strain and Left Atrial Phasic Volumes in Patients Undergoing Transcatheter Valve Implantation for Severe Aortic Stenosis

Cardiology ◽

10.1159/000514665 ◽

2021 ◽

pp. 1-12

Author(s):

Jonathan Weber ◽

Kristine Bond ◽

Joseph Flanagan ◽

Michael Passick ◽

Florentina Petillo ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Left Atrial ◽

Longitudinal Strain ◽

Severe Aortic Stenosis ◽

Sufficient Evidence ◽

Imaging Biomarkers ◽

Peak Longitudinal Strain ◽

Valve Implantation ◽

Global Peak

Introduction: The changes and the prognostic implications of left atrial (LA) volumes (LAV), LA function, and vascular load in patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) are less known. Methods: We enrolled 150 symptomatic patients (mean age 82 ± 8 years, 58% female, and pre-TAVI aortic valve area 0.40 ± 0.19 cm/m2) with severe AS who underwent 2D transthoracic echocardiography and 2D speckle tracking echocardiography at average 21 ± 35 days before and 171 ± 217 days after TAVI. The end point was a composite of new onset of atrial fibrillation, hospitalization for heart failure and all-cause death (major adverse cardiac events [MACE]). Results: After TAVI, indexed maximal LA volume and minimum volume of the LA decreased by 2.1 ± 10 mL/m2 and 1.6 ± 7 mL/m2 (p = 0.032 and p = 0.011, respectively), LA function index increased by 6.8 ± 11 units (p < 0.001), and LA stiffness decreased by 0.38 ± 2.0 (p = 0.05). No other changes in the LA phasic volumes, emptying fractions, and vascular load were noted. Post-TAVI, both left atrial and ventricular global peak longitudinal strain improved by about 6% (p = 0.01 and 0.02, respectively). MACE was reached by 37 (25%) patients after a median follow-up period of 172 days (interquartile range, 20–727). In multivariable models, MACE was associated with both pre- and post-TAVI LA global peak longitudinal strain (hazard ratio [HR] 0.75, CI 0.59–0.97; and HR 0.77, CI 0.60–1.00, per 5 percentage point units, respectively), pre-TAVI LV global endocardial longitudinal strain (HR 1.37, CI 1.02–1.83 per 5 percentage point units), and with most of the LA phasic volumes. Conclusion: Within 6 months after TAVI, there is reverse LA remodeling and an improvement in LA reservoir function. Pre- and post-TAVI indices of LA function and volume remain independently associated with MACE. Larger studies enrolling a greater diversity of patients may provide sufficient evidence for the utilization of these imaging biomarkers in clinical practice.

Download Full-text

Echocardiographic global longitudinal strain as a marker of myocardial fibrosis predicts outcomes in aortic stenosis

European Heart Journal ◽

10.1093/eurheartj/ehab724.1599 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

C Chin ◽

T T Le ◽

G Singh ◽

J Yip ◽

S C Chai ◽

...

Keyword(s):

Aortic Stenosis ◽

Confidence Interval ◽

Myocardial Fibrosis ◽

Prognostic Value ◽

Longitudinal Strain ◽

Severe Aortic Stenosis ◽

Global Longitudinal Strain ◽

Left Ventricular ◽

Derivation Cohort ◽

Replacement Fibrosis

Abstract Background Left ventricular global longitudinal strain (LV-GLS) by speckle tracking echocardiography (STE) reflects intrinsic myocardial function, influenced by interstitial abnormalities. Cardiovascular magnetic resonance (CMR) detects myocardial fibrosis non-invasively, but it is limited for widespread use. We aim to establish LV-GLS as a marker of replacement myocardial fibrosis on CMR and validate the prognostic value of LV-GLS thresholds associated with fibrosis. Methods LV-GLS thresholds of replacement fibrosis were established in the derivation cohort: 151 patients (57±10 years; 58% males) with hypertension who underwent STE to measure LV-GLS and CMR for replacement myocardial fibrosis. Prognostic value of the thresholds was validated in a separate outcome cohort: 261 patients with moderate-severe aortic stenosis (AS; 71±12 years; 58% males; NYHA functional class I-II) and preserved LVEF ≥50%. Primary outcome was a composite of cardiovascular mortality, heart failure hospitalization, myocardial infarction and cerebrovascular events. Results In the derivation cohort, LV-GLS demonstrated good discrimination (c-statistics 0.74; 95% confidence interval: 0.66–0.83; P<0.001) and calibration (Hosmer-Lemeshow X2=6.37; P=0.605) for replacement fibrosis. In the outcome cohort, 52 events occurred over 16 [3.1, 42.0] months of follow-up. Patients with LV-GLS >−15.0% (corresponding to 95% specificity to rule-in myocardial fibrosis) had the worst outcomes compared to patients with LV-GLS <−21.0% (corresponding to 95% sensitivity to rule-out myocardial fibrosis) and those between −21.0 and −15.0% (log-rank P<0.001; Figure 1). Furthermore, LV-GLS offered independent prognostic value over clinical variables, AS severity, echocardiographic LVEF and E/e' (hazard ratio 1.18; 95% confidence interval: 1.07 to 1.30; P=0.001). Conclusions LV-GLS thresholds associated with replacement myocardial fibrosis is a novel approach to risk-stratify patients with AS and preserved LVEF (Figure 2). FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council Figure 1 Figure 2

Download Full-text

P753 Impact of transcatheter aortic valve implantation on concomitant mitral regurgitation in patients with severe aortic stenosis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.417 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

M Lembo ◽

R Sorrentino ◽

C Santoro ◽

R Esposito ◽

M Scalamogna ◽

...

Keyword(s):

Aortic Valve ◽

Mitral Regurgitation ◽

Aortic Stenosis ◽

Left Atrial ◽

Longitudinal Strain ◽

Severe Aortic Stenosis ◽

Valve Surgery ◽

Transcatheter Aortic Valve ◽

Aortic Valve Implantation ◽

Valve Implantation

Abstract Background Severe aortic stenosis (AS) and functional mitral regurgitation (MR) frequently coexist. There is no consensus about the optimal therapeutic strategy for patients with combined valve disease. Evidence has shown that double valve surgery is associated with high complication rates and mortality, whereas MR severity may improve after transcatheter aortic valve implantation (TAVI). Purpose Aim of our study was to evaluate hemodynamic parameters and cardiac function in patients with severe AS and concomitant MR undergoing TAVI. Methods We prospectively enrolled consecutive TAVI patients with concomitant MR. Exclusion criteria were primary cardiomyopathies, prior valve surgery, permanent atrial fibrillation and inadequate echocardiographic imaging. Echo-Doppler assessment, including global longitudinal strain (GLS) and peak atrial longitudinal strain (PALS) (absolute value), was performed before TAVI and after 1-3 months. MR grading was assessed according to quantitative methods (vena contracta and/or PISA). Changes (Δ) of the main echo parameters before and after intervention were computed. On the basis of MR grading changes, the study population was divided in two groups: no improvement in MR grading (NIMR) and improvement in MR grading (IMR). Results Of 49 included patients (M/F = 20/29, age 80.7 ± 5.6 years), 23 had mild MR and 26 moderate to severe MR before TAVI. After the procedure, MR grading improved in 11 (IMR) and remained stable in 38 (NIMR) patients. The two groups were comparable for sex, age, body mass index, blood pressure and heart rate. After TAVI, both groups showed an improvement in GLS (17.8 ± 4.7 to 20.1 ± 4.4%, p < 0.0001 and 16.8 ± 3.8 to 19.0 ± 3.1%, p < 0.01, in NIMR and IMR respectively) and in PALS (20.4 ± 7.4 to 24.2 ± 7.3%, p < 0.0001 in NIMR and 19.5 ± 4.5 to 26.7 ± 6.1%, p < 0.001, in NIMR and IMR respectively), without significant changes in ejection fraction (p = 0.12). Only in IMR group, a significant decrease of systolic pulmonary arterial pressure (sPAP) (45.5 ± 10.6 to 36.3 ± 6.9 mmHg, p < 0.001) and left atrial volume index (54.9 ± 14.8 to 48.9 ± 13.3 ml/m², p < 0.01) was observed after TAVI. Changes of sPAP (ΔsPAP) (9.1 ± 6.4 vs. -0.07 ± 6.7, p < 0.0001) was higher and ΔPALS (-7.2 ± 5.1 vs. -3.8 ± 4.3, p < 0.03) lower in IMR compared with NIMR group (Figure). By a multiple linear regression analysis performed in the pooled population, after adjusting for ΔPALS, Δ aortic valve area and ΔGLS, the association between ΔsPAP and MR grading improvement remained significant (beta = 0.53, p < 0.001) (cumulative R²=0.31, SEE = 6.9 mmHg, p = 0.007). Conclusion Afterload reduction following TAVI may induce hemodynamic changes determining also a reduction in MR severity. This mechanism implies a reduction in left atrial pressure, whose PALS is a reliable marker, and a consequent reduction of post-capillary pulmonary hypertension. The association between MR improvement and ΔsPAP reduction is independent on echocardiographic confounders. Abstract P753 Figure. ΔsPAP and ΔPALS in NIMR and IMR

Download Full-text