scholarly journals Left ventricular myocardial work in patients with high gradient severe symptomatic aortic stenosis

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
G Sa Mendes ◽  
J Abecasis ◽  
S Maltez ◽  
S Guerreiro ◽  
P Freitas ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Tissue Characterization ◽  
Left Ventricular ◽  
Low Flow ◽  
Lv Function ◽  
High Gradient ◽  
Non Invasive ◽  
Lv Ejection Fraction

Abstract Background Left ventricular myocardial work (LVMW) is a novel method to evaluated left ventricular (LV) function using pressure-strain loops. It might correct global longitudinal strain (GLS) for afterload, being eventually useful to assess whether GLS reduction is due to reduced contractility (reflected as reduced myocardial work) or increased afterload (reflected as increased myocardial work). Aim To describe indices of LVMW in a group of patients with severe symptomatic aortic stenosis (AS). Methods We prospectively studied 104 consecutive patients (age: 71 years [IQR 66.5–75.5] years, 51% men) with severe symptomatic high gradient AS: mean transaortic pressure gradient: 56.5mmHg [IQR 46.8–67.8]; aortic valve area: 0.73cm2 [IQR 0.61–0.88]; indexed stroke volume: 47.7±1.3 mL/m2 (11 patients with low-flow AS), preserved LV ejection fraction (EV) (LVEF: 56.0% [51.0–61.3]; GLS: −14.5% [IQR −16.1 to −10.6]), with no previous coronary artery disease and no history of cardiomyopathy. Beyond complete transthoracic echocardiography, all patients underwent cardiac magnetic resonance for LV myocardium tissue characterization. As proposed for AS, LV systolic pressure was corrected adding the mean transaortic pressure gradient to non-invasive systolic blood pressure cuff measurement in the echocardiographic algorithm. Four LVMW indices were collected in 83 patients (patients excluded for atrial fibrillation, left bundle branch block or absence of non-invasive blood pressure registration) and correlated to LV function indexes, LV hypertrophy and remodeling, myocardial tissue characterization, BNP and troponin levels (Pearson or Spearman correlation). These same indexes were compared in patients with LV ejection fraction (EF) below and above 50%, normal and reduced flow and presence of replacement fibrosis. Results Global constructive work (GCW) (2658.6±76.4mmHg%), global myocardial work (GMW) (2218.7±74.9mmHg%) and global wasted work (GWE) (262.0mmHg% [198.8–339.5]) were high above normal with concomitant lower work efficiency (WE) (88.0% [83.2–91.8]. Weak correlations were found between LVMW indexes and parameters describing aortic valve severity, flow and LV function (table). Except for significant differences of LVMI in patients with reduced LV ejection fraction (GCW 2770.3±687.4 vs 2056.0±380.7mmHg%, p=0,014 and GMW 2362.5±657.9 vs 1621.3±319.9, p=0,021 in patients with LV EF>50% vs. LV EF<50%, respectively) work indexes were neither significantly different in low-flow patients nor in those with myocardial late gadolinium enhancement. Conclusions Global constructive and myocardial work are increased in these patients with severe aortic stenosis. This might reflect an increased afterload predominance rather than a LV functional impairment, particularly relevant in this group of patients with exclusive high gradient disease and preserved LVEF. FUNDunding Acknowledgement Type of funding sources: None. Correlations between LVMI – LV function

Abstract 15001: Fusion of Echocardiographic Hemodynamic Data and Computed Tomographic Anatomical Data of the Aortic Valve Determine Severity of Low-Gradient Aortic Stenosis with Preserved Ejection Fraction

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Vasileios Kamperidis ◽  
Philippe J van Rosendael ◽  
Spyridon Katsanos ◽  
Frank van der Kley ◽  
Madelien Regeer ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
Low Flow ◽  
Normal Flow ◽  
Area Index ◽  
High Gradient ◽  
Calcium Load

Introduction: Severe aortic stenosis with preserved left ventricular ejection fraction is classified into 4 groups, according to flow and gradient, with still debatable underlying pathophysiology. Hypothesis: The use of multi-detector computed tomography (MDCT) and Doppler echocardiography refines the differential characteristics and true severity of each aortic stenosis group. Methods: Patients with severe aortic stenosis [aortic valve area index (AVAi) <0.6cm2/m2] and ejection fraction ≥50% (n=191, age 80±7 years, 48.2% male) with echocardiography and MDCT prior to transcatheter aortic valve replacement were included. Patients were classified into 4 groups based on stroke volume index (≤35 or >35 ml/m2) and mean pressure gradient (≤40 or >40mmHg): 1. Normal-flow, high-gradient, 2. Low-flow, high-gradient, 3. Normal-flow, low-gradient, 4. Low-flow, low-gradient. Aortic valve calcium was evaluated on MDCT. Fusion AVAi was estimated by continuity equation using Doppler hemodynamics and MDCT left ventricular outflow tract (LVOT) area. Results: AVAi and LVOT area index were both significantly different among the 4 groups when evaluated by echocardiography. On MDCT, although LVOT area index was comparable among groups, fusion AVAi remained significantly different (Figure): normal-flow, low-gradient had the largest area (0.62±0.11cm2/m2), resulting in reclassification into moderate stenosis in 52% of these patients, while low-flow, low-gradient group had comparable fusion AVAi to normal-flow, high-gradient group. Aortic valve calcium load was largest among patients with high-gradient (median 3412AU for normal-flow and 3181AU for low-flow) and was comparable between patients with low-gradient (2143AU for normal-flow and 2310AU for low-flow). Conclusion: MDCT refines the hemodynamic characterization of low gradient AS patients by providing more accurate AVAi estimation and calcium load.

scholarly journals The association between invasive microvascular function and CMR-derived microvascular injury indicators and left ventricular function and infarct size at 1-month after reperfused STEMI

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
A Demirkiran ◽  
N W Hoeven ◽  
H Everaars ◽  
G N Janssens ◽  
H J Berkhof ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Ejection Fraction ◽  
Linear Regression Analysis ◽  
Left Ventricular ◽  
Coronary Microcirculation ◽  
Microvascular Function ◽  
Lv Function ◽  
Microvascular Injury ◽  
Non Invasive ◽  
Lv Ejection Fraction

Abstract Background The restoration of the coronary microcirculation in ST-segment elevation myocardial infarction (STEMI) patients remains hampered in up to 50% of the STEMI patients after successful primary percutaneous coronary intervention (PCI). The association between the coronary microvascular function and injury indicators and functional outcome remains debated. Purpose This study aims to investigate the relation between post-PCI invasive microvascular function and cardiovascular magnetic resonance (CMR)-derived microvascular injury indicators and left ventricular (LV) function and infarct size (IS) at 1-month after STEMI. Methods The study was performed in 110 STEMI patients who underwent angiography for primary PCI and at 1-month follow-up. Invasive assessment of coronary microcirculation physiology in the culprit artery was performed during both procedures and included coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR). Data were available for 101 patients. A ratio of &gt;2 for CFR and a value of &lt;25 U for IMR were considered normal. CMR was performed during the acute phase (2 to 7 days after PCI) and at 1-month and provided assessment of LV function, IS and non-invasive information of microvascular injury in 78 patients by microvascular obstruction (MVO) and intra-myocardial hemorrhage (IMH). Results Over 1-month, CFR, IMR, LV function, and IS all significantly improved (p≤0.001). In univariable linear regression analysis, the post-PCI normal index CFR and IMR (both p=0.04), MVO presence, MVO size, IMH presence, IMH size (all, p&lt;0.001) were significantly associated with LV ejection fraction at 1-month. Additionally, the post-PCI index CFR (p=0.04), MVO presence, MVO size, IMH presence, IMH size (all, p&lt;0.001) were all associated with 1-month IS. In a multivariable linear regression analysis model including invasive and non-invasive coronary microcirculation function and injury indicators, MVO presence was identified as the only independent marker related to both 1-month LV ejection fraction and IS (both p&lt;0.001). Conclusion(s) In STEMI patients, CMR-derived coronary microcirculation injury indicators reveal a closer association with 1-month LV function and IS outcome than invasive microcirculatory measurements. MVO presence is independently associated with 1-month LV ejection fraction and IS. FUNDunding Acknowledgement Type of funding sources: Private company. Main funding source(s): The REDUCE-MVI study was funded by Astra Zeneca to MvL and NvR.

scholarly journals Valvulo-Arterial Impedance and Dimensionless Index for Risk Stratifying Patients With Severe Aortic Stenosis

2021 ◽  
Vol 8 ◽  
Author(s):  
Yogamaya Mantha ◽  
Shutaro Futami ◽  
Shohei Moriyama ◽  
Michinari Hieda
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Continuous Wave ◽  
Left Ventricular ◽  
Low Flow ◽  
Aortic Valve Area ◽  
Arterial Impedance ◽  
Stenosis Severity ◽  
Lv Ejection Fraction

The hemodynamic effects of aortic stenosis (AS) consist of increased left ventricular (LV) afterload, reduced myocardial compliance, and increased myocardial workload. The LV in AS patients faces a double load: valvular and arterial loads. As such, the presence of symptoms and occurrence of adverse events in AS should better correlate with calculating the global burden faced by the LV in addition to the transvalvular gradient and aortic valve area (AVA). The valvulo-arterial impedance (Zva) is a useful parameter providing an estimate of the global LV hemodynamic load that results from the summation of the valvular and vascular loads. In addition to calculating the global LV afterload, it is paramount to estimate the stenosis severity accurately. In clinical practice, the management of low-flow low-gradient (LF-LG) severe AS with preserved LV ejection fraction requires careful confirmation of stenosis severity. In addition to the Zva, the dimensionless index (DI) is a very useful parameter to express the size of the effective valvular area as a proportion of the cross-section area of the left ventricular outlet tract velocity-time integral (LVOT-VTI) to that of the aortic valve jet (dimensionless velocity ratio). The DI is calculated by a ratio of the sub-valvular velocity obtained by pulsed-wave Doppler (LVOT-VTI) divided by the maximum velocity obtained by continuous-wave Doppler across the aortic valve (AV-VTI). In contrast to AVA measurement, the DI does not require the calculation of LVOT cross-sectional area, a major cause of erroneous assessment and underestimation of AVA. Hence, among patients with LG severe AS and preserved LV ejection fraction, calculation of DI in routine echocardiographic practice may be useful to identify a subgroup of patients at higher risk of mortality who may derive benefit from aortic valve replacement. This article aims to elucidate the Zva and DI in different clinical situations, correlate with the standard indexes of AS severity, LV geometry, and function, and thus prove to improve risk stratification and clinical decision making in patients with severe AS.

LV replacement fibrosis in aortic stenosis: prevalence and relation to LV remodelling and function

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
G Sa Mendes ◽  
J Abecasis ◽  
A Ferreira ◽  
R Ribeiras ◽  
C Saraiva ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Low Flow ◽  
Lv Function ◽  
Aortic Valve Area ◽  
High Gradient ◽  
Lv Mass ◽  
Replacement Fibrosis

Abstract Background Progressive myocardial fibrosis takes part in left ventricular (LV) remodeling in aortic stenosis (AS) and drives the transition from hypertrophy to heart failure. Replacement fibrosis may be characterized by late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR). Aim To assess the prevalence and association between LGE and indexes of LV function in patients with severe aortic stenosis. Methods We prospectively studied 53 consecutive patients (age: 71±8 years [min. 51–max. 84], 54.7% men) with severe symptomatic AS, referred for surgical aortic valve replacement with no previous history of ischemic cardiomyopathy. Aortic valve mean gradient was 54.6 mmHg [IQR 46.6–63.2] and aortic valve area 0.74cm2 [IQR 0.61–0.89]; all patients with high gradient, 4 with low-flow. CMR with tissue characterization (T1 mapping, LGE and extracellular volume by ECV quantification – using 5SD from remote myocardium as signal intensity cut-off), was performed before surgery. AS severity indexes, LV mass, systolic and diastolic LV function indexes including global longitudinal strain (GLS) and torsion were compared in both groups of patients, with and without LGE. Results Mid-wall LGE was present in 36 patients (67.9%) with a median fraction of 6.0% [IQR 4.9–12.7%] of LV mass. Native T1 value and ECV were within normal ranges (median values: 1047ms [IQR 1028–1084]; 22% [IQR 18–25], respectively). Median CMR LV ejection fraction and mass were 64.5% [IQR 51.3–70.8%] (11 patients with reduced EF) and 76.5g/m2 [IQR 57.4–94.8g/m2], respectively. Median GLS was −13.9% [IQR −11.4 to −17.0%] and torsion was 24.2° [IQR 19.8–32.5°]. Patients with LGE had significantly higher LV mass (87.1g/m2 vs 63.3 g/m2, p=0.001), worse GLS (−14.4% vs −16.9%, p=0.041) and higher NT-proBNP values (1333.7ng/mL vs 559.9ng/mL, p=0.004) (Figure). Conclusions Non-ischemic LGE is common in this group of patients with severe symptomatic high gradient aortic stenosis. As it is more prevalent in patients with more pronounced LVH, lower longitudinal deformation and higher NT-proBNP values, it probably represents a more advanced stage of the disease. Funding Acknowledgement Type of funding source: None

Myocardial work in Stage 1 and 2 hypertensive patients

2021 ◽  
Author(s):  
Akshar Jaglan ◽  
Sarah Roemer ◽  
Ana Cristina Perez Moreno ◽  
Bijoy K Khandheria
Keyword(s):  
Ejection Fraction ◽  
Longitudinal Strain ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Hypertensive Patients ◽  
Non Invasive ◽  
Significant Difference ◽  
Lv Ejection Fraction ◽  
Global Work ◽  
Stage 1

Abstract Aims Myocardial work (MW) is a novel parameter that can be used in a clinical setting to assess left ventricular (LV) pressures and deformation. We sought to distinguish patterns of global MW index in hypertensive vs. non-hypertensive patients and to look at differences between categories of hypertension. Methods and results Sixty-five hypertensive patients (mean age 65 ± 13 years; 30 male) and 15 controls (mean age 38 ± 12 years; 7 male) underwent transthoracic echocardiography at rest. Hypertensive patients were subdivided into Stage 1 (n = 32) and Stage 2 (n = 33) hypertension based on 2017 American College of Cardiology guidelines. Exclusion criteria were suboptimal image quality for myocardial deformation analysis, reduced ejection fraction, valvular heart disease, intracardiac shunt, and arrhythmia. Global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency were estimated from LV pressure–strain loops utilizing proprietary software from speckle-tracking echocardiography. LV systolic and diastolic pressures were estimated using non-invasive brachial artery cuff pressure. Global longitudinal strain and LV ejection fraction were preserved between the groups with no statistically significant difference, whereas there was a statically significant difference between the control and two hypertension groups in GWI (P = 0.01), GCW (P &lt; 0.001), and GWW (P &lt; 0.001). Conclusion Non-invasive MW analysis allows better understanding of LV response under conditions of increased afterload. MW is an advanced assessment of LV systolic function in hypertension patients, giving a closer look at the relationship between LV pressure and contractility in settings of increased load dependency than LV ejection fraction and global longitudinal strain.

scholarly journals Non-Invasive Assessment of Left Ventricle Ejection Fraction: Where Do We Stand?

2021 ◽  
Vol 11 (11) ◽  
pp. 1153
Author(s):  
Alessandra Scatteia ◽  
Angelo Silverio ◽  
Roberto Padalino ◽  
Francesco De Stefano ◽  
Raffaella America ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Ejection Fraction ◽  
Systolic Function ◽  
Left Ventricular ◽  
Left Ventricle Ejection Fraction ◽  
Advantages And Disadvantages ◽  
Non Invasive ◽  
Lv Ejection Fraction ◽  
Lv Systolic Function ◽  
Invasive Evaluation

The left ventricular (LV) ejection fraction (EF) is the preferred parameter applied for the non-invasive evaluation of LV systolic function in clinical practice. It has a well-recognized and extensive role in the clinical management of numerous cardiac conditions. Many imaging modalities are currently available for the non-invasive assessment of LVEF. The aim of this review is to describe their relative advantages and disadvantages, proposing a hierarchical application of the different imaging tests available for LVEF evaluation based on the level of accuracy/reproducibility clinically required.

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