Prognostic value of diastolic function parameters in significant aortic regurgitation. The role of the left atrial strain

Abstract Background The management of patients with asymptomatic significant aortic regurgitation (sAR) is often challenging and appropriate timing of aortic valve surgery remains controversial. There are no strong indicators to recommend early surgery in patients with sAR, however delaying the time for the intervention could bring potential negative consequences, such as the risk of permanent left ventricular (LV) dysfunction. The prognostic value of diastolic parameters has been demonstrated in several cardiac diseases. In particular, left atrial (LA) function has been shown to be an important determinant of morbimortality. Purpose The purpose of this study was to analyze the prognostic significance of diastolic function parameters, included LA strain, in asymptomatic patients with sAR and to evaluate whether these parameters could help to identify patients at high risk of adverse events that could benefit from early cardiac surgery. Methods From February 2013 to November 2019 consecutive asymptomatic patients with chronic sAR evaluated in the Heart Valve Clinic with a comprehensive transthoracic echocardiogram (TTE) were included. Combined clinical endpoint included hospital admission due to heart failure, cardiovascular mortality, or indication for aortic valve surgery. Results A total of 126 patients were included. During a mean follow up of 33±19 month, 25 (19.8%) patients reached the combined end-point. In a sub-group of 57 patients with TTE performed in the Philips stations, LA auto-strain analysis was obtained (figure 1). Univariate analysis showed that LV volumes, LVEF, E wave, E/e' ratio, LA volume and LA reservoir strain (LASr) were significant predictors of events, whereas LA diameter, and LV diastolic diameters were not. Multivariate model 1 that tested all echocardiographic variables statistically significant in the univariate model showed that the LVEDV and E/e' ratio, were significant predictors of events. In the subgroup of patients with LA auto-strain analyzed, a second multivariable model was built, including the previous significant variables for the first model (LVEDV and E/e' ratio), as well as the LA volume and LASr. It showed that LVEDV and LASr were the most significant predictors of cardiovascular events (figure 2). Conclusions In this population of asymptomatic patients with sAR and normal LV systolic function, baseline diastolic parameters were prognostic markers of cardiovascular events; among them, LA reservoir strain played a strong independent predictor role. In addition, our results also showed that LV volumes had greater prognostic value that LV diameters in patients with asymptomatic sAR. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2

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PROGNOSTIC VALUE OF DIASTOLIC FUNCTION PARAMETERS IN SIGNIFICANT AORTIC REGURGITATION. THE ROLE OF THE LEFT ATRIAL STRAIN.

10.22541/au.163253231.19489104/v1 ◽

2021 ◽

Author(s):

Ana Garcia-Martin ◽

María Abellás ◽

Ariana González Gómez ◽

Luis Rincon Diaz ◽

Juan Manuel Monteagudo-Ruiz ◽

...

Keyword(s):

Diastolic Function ◽

Aortic Regurgitation ◽

Left Atrial ◽

Cardiovascular Events ◽

Prognostic Value ◽

Systolic Function ◽

Univariate Analysis ◽

Prognostic Significance ◽

Multivariate Model ◽

Asymptomatic Patients

Aims. The management of patients with asymptomatic significant aortic regurgitation (sAR) is often challenging and appropriate timing of aortic valve surgery remains controversial. Prognostic value of diastolic parameters has been demonstrated in several cardiac diseases. In particular, left atrial (LA) function has been shown to be an important determinant of morbimortality. The purpose of this study was to analyze the prognostic significance of diastolic function in asymptomatic patients with sAR. Methods and results. A total of 126 patients with asymptomatic sAR were included. Conventional echocardiographic systolic and diastolic function parameters were assessed. LA auto-strain analysis was performed in a subgroup of 57 patients. During a mean follow up of 33±19 months, 25 (19,8%) patients reached the combined end-point. Univariate analysis showed that LV volumes, LVEF, E wave, E/e’ ratio, LA volume and LA reservoir strain (LASr) were significant predictors of events. Multivariate model 1 that tested all echocardiographic variables statistically significant in the univariate model showed that LVEDV [HR=1,02;95% CI:1,01-1,03 (p<0,001)] and E/e’ ratio [HR=1,12;95% CI:1,03-1,23 (p=0,01)] were significant predictors of events. In the subgroup of patients with LA auto-strain analyzed, a second multivariate model including the previous significant variables for the first model as well as LASr, showed that LVEDV [HR=1,05;95% CI:1,01-1,08 (p=0,016)] and LASr [HR=0,8;95% CI:0,65-0,98 (p<0,035)] were the most significant predictors of cardiovascular events. Conclusions. In this population of asymptomatic patients with sAR and normal LV systolic function, baseline diastolic parameters were prognostic markers of cardiovascular events; among them, LASr played a strong independent predictor role.

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Prognostic implications of left atrial dilation in aortic regurgitation due to bicuspid aortic valve

Heart ◽

10.1136/heartjnl-2020-318907 ◽

2021 ◽

pp. heartjnl-2020-318907

Author(s):

Steele C Butcher ◽

Federico Fortuni ◽

William Kong ◽

E Mara Vollema ◽

Francesca Prevedello ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Bicuspid Aortic Valve ◽

Left Atrial ◽

Valve Surgery ◽

Volume Index ◽

Aortic Valve Surgery ◽

Event Free Survival ◽

Free Survival

ObjectiveTo investigate the prognostic value of left atrial volume index (LAVI) in patients with moderate to severe aortic regurgitation (AR) and bicuspid aortic valve (BAV).Methods554 individuals (45 (IQR 33–57) years, 80% male) with BAV and moderate or severe AR were selected from an international, multicentre registry. The association between LAVI and the combined endpoint of all-cause mortality or aortic valve surgery was investigated with Cox proportional hazard regression analyses.ResultsDilated LAVI was observed in 181 (32.7%) patients. The mean indexed aortic annulus, sinus of Valsalva, sinotubular junction and ascending aorta diameters were 13.0±2.0 mm/m2, 19.4±3.7 mm/m2, 16.5±3.8 mm/m2 and 20.4±4.5 mm/m2, respectively. After a median follow-up of 23 (4–82) months, 272 patients underwent aortic valve surgery (89%) or died (11%). When compared with patients with normal LAVI (<35 mL/m2), those with a dilated LAVI (≥35 mL/m2) had significantly higher rates of aortic valve surgery or mortality (43% and 60% vs 23% and 36%, at 1 and 5 years of follow-up, respectively, p<0.001). Dilated LAVI was independently associated with reduced event-free survival (HR=1.450, 95% CI 1.085 to 1.938, p=0.012) after adjustment for LV ejection fraction, aortic root diameter, LV end-diastolic diameter and LV end-systolic diameter.ConclusionsIn this large, multicentre registry of patients with BAV and moderate to severe AR, left atrial dilation was independently associated with reduced event-free survival. The role of this parameter for the risk stratification of individuals with significant AR merits further investigation.

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Prognostic Value of Diastolic Function Parameters In Significant Aortic Regurgitation. The Role of The Left Atrial Strain

10.21203/rs.3.rs-1231349/v1 ◽

2022 ◽

Author(s):

Ana García-Martín ◽

María Abellás Sequeiros ◽

Ariana González Gómez ◽

Luis Miguel Rincón Díaz ◽

Juan Manuel Monteagudo Ruiz ◽

...

Keyword(s):

Diastolic Function ◽

Aortic Regurgitation ◽

Left Atrial ◽

Prognostic Value ◽

Systolic Function ◽

Univariate Analysis ◽

Prognostic Significance ◽

Left Ventricular ◽

Multivariate Model ◽

Asymptomatic Patients

Abstract AimsThe management of patients with asymptomatic significant aortic regurgitation (sAR) is often challenging and appropriate timing of aortic valve surgery remains controversial. Prognostic value of diastolic parameters has been demonstrated in several cardiac diseases. In particular, left atrial (LA) function has been shown to be an important determinant of morbimortality. The purpose of this study was to analyze the prognostic significance of diastolic function in asymptomatic patients with sAR.Methods and resultsA total of 126 patients with asymptomatic sAR were included. Conventional echocardiographic systolic and diastolic function parameters were assessed. LA and left ventricular (LV) auto-strain analysis was performed in a subgroup of 57 patients. During a mean follow up of 33±19 months, 25(19,8%) patients reached the combined end-point. Univariate analysis showed that LV volumes, LV ejection fraction (LVEF), LV-GLS, E wave, E/e’ ratio, LA volume and LA reservoir strain (LASr) were significant predictors of events. Multivariate model-1 that tested all classical echocardiographic variables statistically significant in the univariate model showed that LVEDV [HR=1,02;95% CI:1,01-1,03;(p<0,001)] and E/e’ ratio [HR=1,12;95% CI:1,03-1,23;(p=0,01)] were significant predictors of events. In the subgroup of patients with auto-strain analyzed, a multivariate model-2 including the previous significant variables for the first model as well as LASr, showed that LVEDV [HR=1,05;95% CI:1,01-1,08;(p=0,016)] and LASr [HR=0,8;95% CI:0,65-0,98;(p<0,035)] were the most significant predictors of cardiovascular events.ConclusionsIn this population of asymptomatic patients with sAR and normal LV systolic function, baseline diastolic parameters were prognostic markers of cardiovascular events; among them, LASr played a strong independent predictor role.

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Faculty Opinions recommendation of Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1087597.540609 ◽

2007 ◽

Author(s):

John A Paraskos

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Left Ventricular Dysfunction ◽

Ventricular Dysfunction ◽

Left Ventricular ◽

Valve Surgery ◽

Aortic Valve Surgery ◽

Severe Left Ventricular Dysfunction ◽

Improved Outcomes ◽

Chronic Aortic Regurgitation

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Echocardiographic Predictors of Left Ventricular Dysfunction after Aortic Valve Surgery in Children with Chronic Aortic Regurgitation

Congenital Heart Disease ◽

10.1111/chd.12009 ◽

2012 ◽

Vol 8 (4) ◽

pp. 308-315 ◽

Cited By ~ 8

Author(s):

Elif Seda Selamet Tierney ◽

Dana Gal ◽

Kimberly Gauvreau ◽

Jing Zhou ◽

Yelda Soluk ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Left Ventricular Dysfunction ◽

Ventricular Dysfunction ◽

Left Ventricular ◽

Valve Surgery ◽

Aortic Valve Surgery ◽

Chronic Aortic Regurgitation

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101 Quantifying aortic regurgitation with CMR can predict patients requiring aortic valve surgery

Journal of Cardiovascular Magnetic Resonance ◽

10.1186/1532-429x-10-s1-a2 ◽

2008 ◽

Vol 10 (S1) ◽

Cited By ~ 1

Author(s):

Saul G Myerson ◽

Theodoros D Karamitsos ◽

Jane M Francis ◽

Adrian P Banning ◽

Stefan Neubauer

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Valve Surgery ◽

Aortic Valve Surgery

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Layer-specific longitudinal strain detects transmural dysfunction in chronic severe aortic regurgitation before and after aortic valve surgery

The International Journal of Cardiovascular Imaging ◽

10.1007/s10554-021-02492-w ◽

2021 ◽

Author(s):

Frederik Fasth Grund ◽

Charlotte Burup Kristensen ◽

Hashmat Sayed Zohori Bahrami ◽

Rasmus Mogelvang ◽

Christian Hassager

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Longitudinal Strain ◽

Valve Surgery ◽

Aortic Valve Surgery ◽

Severe Aortic Regurgitation ◽

Before And After

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Aortic regurgitation

ESC CardioMed ◽

10.1093/med/9780198784906.003.0765 ◽

2018 ◽

pp. 1634-1641

Author(s):

Pilar Tornos Mas ◽

Emmanuel Lansac

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Aortic Surgery ◽

Valve Surgery ◽

Aortic Dilatation ◽

Concomitant Surgery ◽

Asymptomatic Patients ◽

Aortic Pathology ◽

Definition Of ◽

And Function

Evaluation of aortic regurgitation requires consideration of valve morphology, mechanism and severity of regurgitation and assessment of aortic dilatation. In asymptomatic patients with severe aortic regurgitation, follow-up of symptomatic status and LV size and function is mandatory. The strongest indication for valve surgery is the presence of symptoms and/or the documentation of LVEF <50% and/or end-systolic diameter =50 mm. In patients with dilated aorta, definition of aortic pathology and accurate measurements of aortic diameters are crucial. Surgery is recommended whenever aortic dilation is = 55 mm or = 50 mm in patients with bicuspid aortic valves and Marfan syndrome or =45 mm when additional risk factors are present. For patients who have an indication for valve surgery, an aortic diameter of ≥45 mm is considered to indicate concomitant surgery of the aorta. Aortic valve repair and valve-sparing aortic surgery instead of aortic valve replacement should be considered in selected cases in experienced centres.

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Time course of left ventricular remodelling and mechanics after aortic valve surgery: aortic stenosis vs. aortic regurgitation

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez049 ◽

2019 ◽

Vol 20 (10) ◽

pp. 1105-1111

Author(s):

E Mara Vollema ◽

Gurpreet K Singh ◽

Edgard A Prihadi ◽

Madelien V Regeer ◽

See Hooi Ewe ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Regurgitation ◽

Time Course ◽

Pressure Overload ◽

Volume Overload ◽

Left Ventricular ◽

Valve Surgery ◽

Aortic Valve Surgery ◽

Lv Mass

Abstract Aims Pressure overload in aortic stenosis (AS) and both pressure and volume overload in aortic regurgitation (AR) induce concentric and eccentric hypertrophy, respectively. These structural changes influence left ventricular (LV) mechanics, but little is known about the time course of LV remodelling and mechanics after aortic valve surgery (AVR) and its differences in AS vs. AR. The present study aimed to characterize the time course of LV mass index (LVMI) and LV mechanics [by LV global longitudinal strain (LV GLS)] after AVR in AS vs. AR. Methods and results Two hundred and eleven (61 ± 14 years, 61% male) patients with severe AS (63%) or AR (37%) undergoing surgical AVR with routine echocardiographic follow-up at 1, 2, and/or 5 years were evaluated. Before AVR, LVMI was larger in AR patients compared with AS. Both groups showed moderately impaired LV GLS, but preserved LV ejection fraction. After surgery, both groups showed LV mass regression, although a more pronounced decline was seen in AR patients. Improvement in LV GLS was observed in both groups, but characterized by an initial decline in AR patients while LV GLS in AS patients remained initially stable. Conclusion In severe AS and AR patients undergoing AVR, LV mass regression and changes in LV GLS are similar despite different LV remodelling before AVR. In AR, relief of volume overload led to reduction in LVMI and an initial decline in LV GLS. In contrast, relief of pressure overload in AS was characterized by a stable LV GLS and more sustained LV mass regression.

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