Relationship between Longitudinal Strain and Symptomatic Status in Aortic Stenosis

doi:10.1016/j.echo.2013.05.004

Journal of the American Society of Echocardiography

Volume 26, Issue 8, August 2013, Pages 868-874

https://doi.org/10.1016/j.echo.2013.05.004 Get rights and content

Background

Global longitudinal strain (GLS) and basal longitudinal strain (BLS) assessed using two-dimensional speckle-tracking imaging have been proposed as subtle markers of left ventricular (LV) systolic dysfunction with potential prognostic value in patients with aortic stenosis (AS). The aim of this study was to evaluate the relationship between longitudinal strain and symptomatic status in patients with AS.

Methods

GLS and BLS were measured in 171 patients with pure, isolated, at least mild AS prospectively enrolled at two institutions. The population was divided into four groups: asymptomatic nonsevere AS (n = 55), asymptomatic severe AS with preserved LV ejection fraction (LVEF; ≥50%) (n = 37), symptomatic severe AS with preserved LVEF (n = 60), and severe AS with reduced LVEF (<50%) (n = 19).

Results

GLS was significantly different among the four groups (P < .0001), but the difference was due mainly to patients with reduced LVEFs. In addition, there was an important overlap among the groups, and in multivariate analysis, after adjustment for age, gender, AS severity, and LVEF, GLS was not an independent predictor of symptomatic status (P = .07). BLS was also significantly different among the four groups (P < .0001) but in contrast was independently associated with symptomatic status (P < .0001). However, as for GLS, there was an important overlap between groups and differences were close to intraobserver or interobserver variability (1.3 ± 1.1% and 2.0 ± 1.6%, respectively).

Conclusions

In this prospective multicenter cohort of patients with wide ranges of AS severity, symptoms, and LVEFs, BLS but not GLS was independently associated with symptomatic status. However, there was an important overlap among groups, and differences were close to measurements' reproducibility, raising caution regarding the use of longitudinal strain, at least as a single criterion, in the decision-making process for patients with severe asymptomatic AS.

Section snippets

Study Population

We prospectively enrolled patients with AS at two institutions (Bichat Hospital, Paris, France, and Henri-Mondor Hospital, Creteil, France) from February 2009 to June 2010. The inclusion criterion was pure, at least mild AS (defined by a mean pressure gradient [MPG] > 10 mm Hg). Exclusion criteria were more than mild coexisting aortic regurgitation (defined by a vena contracta width ≥ 3 mm or a regurgitant volume ≥ 30 mL)⁹ or other valvular heart disease, segmental LV wall motion abnormality

Population Characteristics

We prospectively enrolled 171 patients (mean age, 73 ± 12 years; 40% women) with at least mild AS from two centers (127 from Bichat Hospital and 44 from Henri-Mondor Hospital). Hypertension was present in 65% of patients, and 17% had known histories of CAD. The mean LVEF was 62 ± 9% (median, 65%; range, 25%–79%), and most patients had preserved LVEFs (≥50% in 89% of patients). The mean AVA was 0.99 ± 0.43 cm² (median, 0.93 cm²; range, 0.30–2.00 cm²), the mean MPG was 44 ± 23 mm Hg (median, 42

Discussion

In the present study, in a two-center cohort of patients with wide ranges of symptoms, LVEFs, and AS severity, we showed that BLS but not GLS was independently associated with symptomatic status. However, there was an important overlap among groups, and absolute differences of either GLS or BLS between symptomatic and asymptomatic patients with severe AS and preserved LVEFs were close to measurements' reproducibility. Thus, our results raise caution regarding the sole use of longitudinal

Conclusions

In this prospective two-center cohort of patients with wide ranges of AS severity, symptoms, and ejection fractions, we showed that BLS but not GLS was independently associated with symptomatic status. However, differences between groups were small, close to measurements' reproducibility, with an important overlap among subgroups, raising caution regarding the use of longitudinal strain, at least as a single criterion, in the decision-making process of patients with severe asymptomatic AS.

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Cited by (52)

Association Between Left Ventricular Apical-to-Basal Strain Ratio and Conduction Disorders after Aortic Valve Replacement
2024, Journal of the American Society of Echocardiography
The aim of the study was to evaluate whether left ventricular apical-to-basal longitudinal strain differences, representing advanced basal interstitial fibrosis, are associated with conduction disorders after aortic valve replacement (AVR) in patients with severe aortic stenosis.
Patients with aortic stenosis undergoing AVR were included. The apical-to-basal strain ratio was calculated by dividing the average strain of the apical segments by the average strain of the basal segments. Values >1.9 were considered abnormal, as previously described. All patients were followed up for the occurrence of complete left or right bundle branch block or permanent pacemaker implantation within 2 years after AVR. Subgroup analysis was performed in patients undergoing transcatheter AVR.
Two hundred seventy-four patients were included (median age of 74 years [interquartile range, 65, 80], 46.4% male). During a median follow-up of 12.2 months (interquartile range, 0.2, 24.3), 74 patients (27%) developed complete bundle branch block or were implanted with a permanent pacemaker. These patients more often had an abnormal apical-to-basal strain ratio. Cumulative event-free survival analysis showed worse outcome in patients with an abnormal apical-to-basal strain ratio (log rank χ² = 7.258, P = .007). In multivariable Cox regression analysis, an abnormal apical-to-basal strain ratio was the only independent factor associated with the occurrence of complete bundle branch block or permanent pacemaker implantation after adjusting for other factors previously shown to be associated with conduction disorders after AVR. Subgroup analysis confirmed the independent association of an abnormal apical-to-basal strain ratio with conduction disorders after transcatheter AVR.
The apical-to-basal strain ratio is independently associated with conduction disorders after AVR and could guide risk stratification in patients potentially at risk for pacemaker implantation.
Association of acute improvement in left ventricular longitudinal function after transcatheter aortic valve implantation with outcomes for severe aortic stenosis and preserved ejection fraction
2023, Journal of Cardiology
Global longitudinal strain (GLS) is reportedly a sensitive marker for early subtle abnormalities in left ventricular (LV) performance of asymptomatic patients with severe aortic stenosis (AS) and preserved LV ejection fraction (LVEF). For symptomatic patients with severe AS and preserved LVEF, however, the association of immediate improvement in GLS after transcatheter aortic valve implantation (TAVI) with long-term outcomes remains uncertain.
This study concerned 151 symptomatic patients with severe AS and preserved LVEF who had undergone TAVI. Echocardiography was performed before TAVI and 7 (7–9) days after TAVI. GLS was determined by means of a two-dimensional speckle-tracking strain using current guidelines. The primary endpoint was defined as a composite endpoint comprising cardiovascular death or re-hospitalization for HF after TAVI over a median follow-up period of 27.7 (11.9–51.4) months.
Mean LVEF and GLS were 65 ± 7 % and 12.8 ± 3.4 %, respectively. The Kaplan-Meier curve indicated that patients with acute improvement in GLS after TAVI experienced fewer cardiovascular events than those without such improvement (log-rank P = 0.02). Multivariate analysis showed that non-acute improvement in GLS after TAVI was independently associated with worse outcomes as well as deterioration of the mean transaortic pressure gradient.
Assessment of GLS immediately after TAVI is a valuable additional parameter for better management of symptomatic patients with severe AS and preserved LVEF who are scheduled for TAVI.
Strain Imaging: An Everyday Tool for the Perioperative Echocardiographer
2020, Journal of Cardiothoracic and Vascular Anesthesia
Strain analysis allows for global and regional analysis of myocardial function and has been shown to be an independent predictor of outcomes after cardiac surgery. Strain imaging offers advantages over traditional EF measurements in that it is relatively angle independent, it is less dependent upon loading conditions, it is reproducible, it does not rely on geometric assumptions, and it can detect subclinical systolic dysfunction. Limitations of strain analysis include high temporal resolution requirements, a strong dependence on image quality, and inter-vendor variability. In addition, there is a paucity of data on the intraoperative applications of strain. The ASE has defined a global longitudinal strain of –20% measured by transthoracic echocardiography to be considered normal, with less negative values considered abnormal. Presently, there are no published guidelines on the normal values of strain with transesophageal echocardiography (TEE). However, multiple studies have shown that a reduction in intraoperative strain assessed with TEE has been shown to be an independent predictor of complications during cardiac surgery. Accordingly, further incorporation of intraoperative strain analysis with TEE could aid in prognostication for patients undergoing cardiac surgery. As perioperative strain analysis continues to advance, an understanding of these concepts is imperative for perioperative echocardiographers. It is the authors’ goal to show that strain imaging can provide a reliable and objective measure that can be performed in real time to aid in decision-making and perioperative risk stratification.
The Association Between Longitudinal Strain at Rest and Stress and Outcome in Asymptomatic Patients With Moderate and Severe Aortic Stenosis
2019, Journal of the American Society of Echocardiography
Citation Excerpt :
In this study, the difference between GLS and BLS was significantly lower compared with the study by Lafitte et al.17 The reasons for the changes in the values in GLS and BLS between the studies may be related to differences in the studied population, including AS severity and the presence of coronary disease. This may also be related to image quality and to software version.35,36 There are no reports on the significance of peak exercise BLS in asymptomatic patients with AS.
Calcific aortic stenosis (AS) is a progressive disease, and once moderate AS is present, the likelihood of symptom onset within 5 years is significant. The aim of this study was to determine the incremental value of global longitudinal strain (GLS) and basal longitudinal strain (BLS) at rest and during exercise on outcomes among asymptomatic patients' with moderate and severe AS.
Seventy-five patients with isolated, asymptomatic AS and preserved left ventricular function were retrospectively enrolled and underwent symptom-limited exercise echocardiography. Clinical and echocardiographic data, including GLS and BLS at rest and during exercise, were assessed. Occurrence of AS-related cardiovascular events was recorded.
The mean age was 71 ± 10 years, and 63% were men. The mean aortic valve gradient was 30 ± 11 mm Hg, and the mean aortic valve area was 0.98 ± 0.21 cm². Resting GLS and BLS were −16.5 ± 4% and −16.9 ± 3.6%, respectively. Exercise stress test results were positive in 27 patients (36%). Mean exercise GLS was −17.8 ± 3.5%, and mean exercise BLS was −17.9 ± 4%. During mean follow-up of 34.5 ± 3.5 months, cardiovascular events were observed in 45 patients. In multivariate analysis, aortic valve mean gradient (HR, 1.073; 95% CI, 1.032–1.115; P < .001) and peak exercise BLS (HR, 1.177; 95% CI, 1.07–1.295; P = .001) were associated with cardiac events during follow-up.
Reduced exercise BLS is associated with future cardiovascular events in patients' with asymptomatic AS, independently of clinical factors and conventional echocardiographic parameters. Detection of postexercise myocardial dysfunction in patients with asymptomatic AS with preserved left ventricular function can aid in risk assessment of these patients.
Echocardiographic Imaging for Transcatheter Aortic Valve Replacement
2018, Journal of the American Society of Echocardiography
Transcatheter aortic valve replacement has become an accepted alternative to surgery for patients with severe, symptomatic aortic stenosis who are inoperable or are at high surgical risk. Recent trials support the use of transcatheter aortic valve replacement also in patients at intermediate risk, and ongoing trials are assessing appropriateness in other patient groups. The authors review the key anatomic features integral to the transcatheter aortic valve replacement procedure and the echocardiographic imaging required for preprocedural, intraprocedural, and postprocedural assessment.
Prognostic Value of Left Ventricular Deformation Parameters in Patients with Severe Aortic Stenosis: A Pilot Study of the Usefulness of Strain Echocardiography
2017, Journal of the American Society of Echocardiography
Citation Excerpt :
On the basis of our studies of healthy control subjects and different cardiomyopathies, mechanical dispersion > 65 to 70 msec seems to be an equitable cutoff value in patients with severe AS, in whom fibrosis, ischemia, and ventricular arrhythmias might promote adverse outcomes. The presence of abnormal LV mechanics in patients with AS and preserved LVEFs is well known.26-29 Previous studies have shown that these patients have reduced longitudinal myocardial function that improves after AVR.30
In patients with aortic stenosis, subtle alterations in myocardial mechanics can be detected by speckle-tracking echocardiography before reduction of left ventricular ejection fraction (LVEF).
In this prospective study, 162 patients with aortic stenosis with an average aortic valve area of 0.7 ± 0.2 cm² and a mean LVEF of 60 ± 11% were included. Global longitudinal strain (GLS) and mechanical dispersion (SD of time from Q/R on the electrocardiogram to peak strain in 16 left ventricular segments) were assessed using echocardiography, and all-cause mortality (n = 37) was recorded during 37 ± 13 months of follow-up.
Overall, nonsurvivors had more pronounced mechanical dispersion and worse GLS compared with survivors (74 ± 24 vs 61 ± 18 msec [P < .01] and −14.5 ± 4.4% vs −16.7 ± 3.6% [P < .01], respectively). In the 42 conservatively treated patients without surgical aortic valve replacement, a similar pattern was observed in nonsurvivors versus survivors (mechanical dispersion, 80 ± 24 vs 57 ± 14 msec [P < .01]; GLS, −14.0 ± 4.9% vs −17.1 ± 3.8% [P = .04], respectively). Mechanical dispersion was significantly associated with mortality (hazard ratio per 10-msec increase, 1.23; 95% CI, 1.07–1.42; P < .01) in a Cox model adjusted for LVEF and with aortic valve replacement treatment as a time-dependent covariate. Continuous net reclassification improvement showed that mechanical dispersion was incremental to LVEF, GLS, and valvulo-arterial impedance when adjusting for aortic valve replacement treatment in the total population.
Increased mechanical dispersion may be a risk marker providing novel prognostic information in patients with aortic stenosis.

View all citing articles on Scopus

: The Aortic Stenosis in Elderly: Determinant of Progression (COFRASA) and Genetic of Aortic Valve Stenosis: Clinical and Therapeutic Implications (GENERAC) studies are supported grants from Assistance Publique – Hôpitaux de Paris (PHRC National 2005 and PHRC Regional 2007) (ClinicalTrials.gov NCT00338676 and NCT00647088).

View full text

Clinical InvestigationValvular Heart DiseaseRelationship between Longitudinal Strain and Symptomatic Status in Aortic Stenosis

Background

Methods

Results

Conclusions

Section snippets

Study Population

Population Characteristics

Discussion

Conclusions

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

Am J Cardiol

Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)

Eur Heart J

Circulation

Survival after valve replacement for aortic stenosis: implications for decision making

J Thorac Cardiovasc Surg

A mathematical model of the dynamic geometry of the intact left ventricle and its application to clinical data

Circulation

Strain analysis in patients with severe aortic stenosis and preserved left ventricular ejection fraction undergoing surgical valve replacement

Eur Heart J

Myocardial deformation in aortic valve stenosis: relation to left ventricular geometry

Heart

Clinical Investigation
Valvular Heart Disease
Relationship between Longitudinal Strain and Symptomatic Status in Aortic Stenosis