Alterations in multidirectional myocardial functions in patients with aortic stenosis and preserved ejection fraction: a two-dimensional speckle tracking analysis

Ng, Arnold C.T.; Delgado, Victoria; Bertini, Matteo; Antoni, M. Louisa; Bommel, Rutger J. van; Rijnsoever, Eva P.M. van; Kley, Frank van der; Ewe, See Hooi; Witkowski, Tomasz; Auger, Dominique; Nucifora, Gaetano; Schuijf, Joanne D.; Poldermans, Don; Leung, Dominic Y.; Schalij, Martin J.; Bax, Jeroen J.

doi:10.1093/eurheartj/ehr084

Cited by 209 publications

(154 citation statements)

References 24 publications

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“…In our opinion, however, it is not surprising, but rather reassuring, that patients from Group 2, which present with the most severe forms of AS, also present with the lowest global longitudinal strain, because subtle left ventricular dysfunction has been extensively evidenced in this setting of high-gradient AS. 5,6 The fact that similar findings were observed in patients with low-flow, low-gradient AS (Group 4) in our series is much more interesting and clearly demonstrated by our data, although its prognostic significance remains unknown.Although we can regret that Dr Ozkan was not able to report his own experience on the topic, we hope that he will keep in mind the main and objective results of our study: (1) subtle left ventricular dysfunction can be evidenced by 2-dimensional strain in the majority of patients with severe AS and normal left ventricular ejection fraction; (2) longitudinal left ventricular dysfunction is particularly severe in AS with low cardiac output, including low-flow, highgradient and low-flow, low-gradient AS; and (3) the prognostic significance of these findings needs further investigation. 7…”

supporting

confidence: 85%

Response to Letter Regarding Article, “Low-Flow, Low-Gradient Severe Aortic Stenosis Despite Normal Ejection Fraction Is Associated With Severe Left Ventricular Dysfunction as Assessed by Speckle-Tracking Echocardiography: A Multicenter Study”

Adda¹,

Mielot

Giorgi

et al. 2012

Circ: Cardiovascular Imaging

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We read the comments of Dr Ozkan and would like to answer his questions and remarks.Concerning left ventricular midwall fractional shortening, it is known for a long time that it is impaired in severe aortic stenosis (AS). Midwall fractional shortening has been shown to be particularly reduced in low-flow, low-gradient AS, as shown by Hachicha et al 1 and confirmed in our study. 2 In both studies, midwall fractional shortening was particularly low in the group of low-flow AS, although the difference was not significant in our study (Pϭ0.07), probably related to the small sample size in each subgroup.Dr Ozkan underlines that values of basal strain as low as Ϫ13.9% have been reported in normal individuals, 3,4 meaning that the low basal strain observed in patients with AS in our study does not systematically represent left ventricular dysfunction. However, a careful reading of those series allows us to reach opposite conclusions. Although lower deformations of basal left ventricular segments, in particular in the inferoseptum (Ϫ14.6%) and the anteroseptum (Ϫ13.9%), were observed in normal subjects, 3 the average basal longitudinal strain in the same patients was higher, reaching Ϫ16.2%Ϯ4.3% in 1 study 3 and Ϫ17%Ϯ5.2% in the other, 4 respectively. The values observed in our study in patients with AS were clearly lower in all groups, particularly in patients with reduced flow, with an average basal longitudinal strain of Ϫ10.9%Ϯ2.8% in Group 2 and Ϫ11.6%Ϯ3.4% in Group 4, respectively, thus representing severe left ventricular basal longitudinal dysfunction in both situations.We agree with Dr Ozkan that symptoms are very important prognostic markers in AS. In our study, 2 70 (20.6%) of 340 patients were asymptomatic. However, the purpose of our study was not to assess the prognostic value of strain, but rather to study the relationship between the type of AS (particularly low-flow, lowgradient AS) and the severity of left ventricular longitudinal dysfunction, irrespective of the clinical status of the patient. We hope that strain measurements will help clinicians to obtain risk stratification in asymptomatic patients with severe AS. However, the prognostic value of left ventricular longitudinal dysfunction in low-flow, low-gradient AS needs further investigation.Finally, Dr Ozkan focused on the fact that highest values of valvulo-arterial impedance and lowest global longitudinal strain were found in Group 2 (low flow high gradient) rather than in Group 4 (low flow, low gradient). In our opinion, however, it is not surprising, but rather reassuring, that patients from Group 2, which present with the most severe forms of AS, also present with the lowest global longitudinal strain, because subtle left ventricular dysfunction has been extensively evidenced in this setting of high-gradient AS. 5,6 The fact that similar findings were observed in patients with low-flow, low-gradient AS (Group 4) in our series is much more interesting and clearly demonstrated by our data, although its prognostic significance remains unknown....

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confidence: 85%

Response to Letter Regarding Article, “Low-Flow, Low-Gradient Severe Aortic Stenosis Despite Normal Ejection Fraction Is Associated With Severe Left Ventricular Dysfunction as Assessed by Speckle-Tracking Echocardiography: A Multicenter Study”

Adda¹,

Mielot

Giorgi

et al. 2012

Circ: Cardiovascular Imaging

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“…[12][13][14][15][16] In hypertension, it has been demonstrated that afterload per se affects longitudinal systolic function 17 with a compensatory increased contribution to ventricular emptying from radial LV fibers, thereby maintaining LVEF. In the present study, this understanding was extended to patients with AS where we found GLS was associated with global LV afterload (Z va ) after adjustment for confounders.…”

Section: Discussionmentioning

confidence: 99%

Global Strain in Severe Aortic Valve Stenosis

Dahl

Videbæk

Poulsen

et al. 2012

Circ: Cardiovascular Imaging

150

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The present study is a prespecified substudy of a prospective single-center randomized study to evaluate the effect of candesartan compared with conventional treatment on reverse remodeling in Background-Global longitudinal systolic strain (GLS) is often reduced in aortic stenosis despite normal ejection fraction.The importance of reduced preoperative GLS on long-term outcome after aortic valve replacement is unknown. Methods and Results-A total of 125 patients with severe aortic stenosis and ejection fraction >40% scheduled for aortic valve replacement were evaluated preoperatively and divided into 4 groups according to GLS quartiles. Patients were followed up for 4 years. The primary end points were major adverse cardiac events (MACEs) defined as cardiovascular mortality and cardiac hospitalization because of worsening of heart failure; the secondary end point was cardiovascular mortality. MACE and cardiac mortality were significantly increased in patients with lower GLS. Estimated 5-year MACE was increased: first quartile 19% (n=6) / second quartile 20% (n=6) / third quartile 35% (n=11) / fourth quartile 49% (n=15); P=0.04. Patients with increased age, left ventricular hypertrophy, and left atrial dilatation were at increased risk. In Cox regression analysis, after correcting for standard risk factors and ejection fraction, GLS was found to be significantly associated with cardiac morbidity and mortality. In a stepwise Cox model with forward selection, GLS was the sole independent predictor: hazard ratio=1.13 (95% confidence interval, 1.02-1.25), P=0.04. Comparing the overall log likelihood χ 2 of the predictive power of the multivariable model containing GLS was statistically superior to models based on EuroScore, history with ischemic heart disease, and ejection fraction. Conclusions-In Screening and InclusionPatients eligible for the study were aged >18 years with symptomatic severe AS (estimated aortic valve area<1 cm 2 ) scheduled for AVR at Odense University Hospital during the period February 2006 and May 2008. Patients with LV systolic dysfunction (LVEF<40%), renal failure (s-creatinine >220 μmol/L), previous aortic valve surgery, planned additional valve repair/replacement, acute infective endocarditis, predominantly aortic valve regurgitation, or treatment with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker at the time of enrolment were excluded. The need for AVR was decided by consensus among senior cardiologists, cardiac surgeons, and anesthetists not involved in the present study. Of the 238 patients screened for participation, 49 refused participation in the study, 59 met at least 1 exclusion criteria, and 5 did not undergo surgery, leaving 125 patients in the study. Patients were divided into 4 groups according to global strain quartiles.The severity of preoperative symptoms was evaluated using the New York Heart Association (NYHA) functional class for dyspnea and the Canadian Cardiovascular Society (CCS) functional class for angina.Ischemic heart disease was def...

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“…Accordingly, several studies report that up to one third of asymptomatic patients with preserved LVEF have a significant impairment of intrinsic myocardial systolic function as documented by parameters of LV longitudinal function. [16][17][18] Furthermore, these parameters have been shown to be superior to LVEF to predict adverse outcomes in AS. [16][17][18][19][20] From a pathophysiological standpoint, these data are consistent with the concept that the increase in wall stress and intra-myocardial pressure as well as the reduction in M A N U S C R I P T…”

Section: Amount and Distribution Of Adiposity Versus LV Systolic Dysfmentioning

confidence: 99%

Visceral Adiposity and Left Ventricular Mass and Function in Patients With Aortic Stenosis: The PROGRESSA Study

Capoulade

Larose

Mathieu

et al. 2014

Canadian Journal of Cardiology

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Brief SummaryThe purpose of this study was to examine the association between amount and distribution of body fat and LV hypertrophy and systolic dysfunction in aortic stenosis (AS) patients. The increased total adiposity as well as a high proportion of visceral adipose tissue (VAT) are both associated with LV hypertrophy, independent of AS severity and hypertension. The excess VAT and a high proportion of VAT relative to total adipose tissue are independently associated with impaired LV systolic function in AS. M A N U S C R I P T A C C E P T E D ACCEPTED MANUSCRIPT 3 ABSTRACTBackground: Recent studies have reported that obesity, metabolic syndrome, and diabetes are

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Alterations in multidirectional myocardial functions in patients with aortic stenosis and preserved ejection fraction: a two-dimensional speckle tracking analysis

Cited by 209 publications

References 24 publications

Response to Letter Regarding Article, “Low-Flow, Low-Gradient Severe Aortic Stenosis Despite Normal Ejection Fraction Is Associated With Severe Left Ventricular Dysfunction as Assessed by Speckle-Tracking Echocardiography: A Multicenter Study”

Response to Letter Regarding Article, “Low-Flow, Low-Gradient Severe Aortic Stenosis Despite Normal Ejection Fraction Is Associated With Severe Left Ventricular Dysfunction as Assessed by Speckle-Tracking Echocardiography: A Multicenter Study”

Global Strain in Severe Aortic Valve Stenosis

Visceral Adiposity and Left Ventricular Mass and Function in Patients With Aortic Stenosis: The PROGRESSA Study

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