Increased Left Ventricular Diastolic Stiffness Is Associated With Heart Failure Symptoms in Aortic Stenosis Patients With Preserved Ejection Fraction

Kamimura, Daisuke; Suzuki, Takeki; Fox, Ervin R.; Hall, Michael E.

doi:10.1016/j.cardfail.2017.05.002

Cited by 10 publications

(8 citation statements)

References 31 publications

(46 reference statements)

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“…LV diastolic dysfunction, and subsequently indices of LV myocardial and chamber stiffness had been associated with symptomatic AS, especially dyspnea 30 . These findings had suggested that heart failure symptoms in severe AS were driven by high LV filling pressures consequent to LV hypertrophy and diastolic dysfunction 31 . The actual relationship between LV remodeling and diastolic filling however is highly complex, where both early relaxation and passive LV filling later in diastole have demonstrated important roles in the development of heart failure symptoms 32 .…”

Section: Discussionmentioning

confidence: 99%

Novel Echocardiography-Derived Left Ventricular Stiffness Index in Low-Flow Versus Normal-Flow Severe Aortic Stenosis with Preserved Left Ventricular Ejection Fraction

Ngiam

Chew

Tan

et al. 2020

Sci Rep

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Background Paradoxical low-flow (LF) severe aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF) may have poorer prognosis than normal-flow (NF) AS, though its pathophysiology remained unclear. In particular, LV stiffness has not been compared between LF vs NF. We used a novel echocardiography-derived index of LV stiffness to compare between these groups. Consecutive patients with medically-managed isolated severe AS (aortic valve area < 1 cm 2) and preserved LVEF (>50%) were studied. Echocardiographic LV stiffness index was measured by a method previously validated against cardiac catheterization. We compared LF (stroke volume index, SVI < 35 ml/m 2) and NF severe AS. Of the 352 patients, 121 (34%) were LF. Both LF and NF groups had similar demographics, valve areas and indices. Compared to NF, LF severe AS had higher LV stiffness indices (>0.11 ml −1 OR 3.067, 95% CI 1.825-5.128, p < 0.001). Increased LV stiffness was associated with concentric remodelling and more severe diastolic dysfunction, especially in LF AS. An LV stiffness index of > 0.11 ml −1 was independently associated with increased mortality, after adjusting for age, clinical and echocardiographic parameters (HR 2.283 95% CI 1.318-3.968, p = 0.003). Non-invasive echocardiographic-derived index of LV stiffness may be important in LF AS. Increased LV stiffness was related to LV concentric remodelling and diastolic dysfunction, and associated with poorer clinical outcomes in medically-managed AS. Significant differences in echocardiographic profiles exist between paradoxical low-flow (LF) and normal-flow (NF) severe aortic stenosis (AS). This may be due to differences in pathophysiological processes in the natural history of LF compared to NF AS. Of note, left ventricular (LV) stiffness has not been evaluated in AS. Conventional measurement of LV stiffness involves using invasive cardiac catheterization and determination of the end-diastolic pressure-volume relationship by pressure-volume loop analysis 1. This is impractical for routine serial evaluation in AS as it requires invasive cardiac catheterization 2,3. AS remains an important disease because of its high prevalence. It affects approximately 5% of patients over 75 years of age, and is associated with reduced survival 4,5. LF AS (LV stroke volume index (SVI) < 35 mL/m 2) despite preserved left ventricular ejection fraction (LVEF), termed "paradoxical low-flow", has been increasingly recognised as a subgroup of severe AS that portends a worse prognosis compared to normal-flow 6. However, the differential effects of the aortic valve pathology on the LV in LF compared to NF AS, particularly LV stiffness, remains to be elucidated 7-9 .

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Section: Discussionmentioning

confidence: 99%

Novel Echocardiography-Derived Left Ventricular Stiffness Index in Low-Flow Versus Normal-Flow Severe Aortic Stenosis with Preserved Left Ventricular Ejection Fraction

Ngiam

Chew

Tan

et al. 2020

Sci Rep

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“…0.33 had a higher rate of death or HF hospitalization than those with DWS > 0.33, even after adjustment for age, sex, log B-type natriuretic peptide, LV geometry and log E/e'. Similarly, Kamimura D et al (49) in 2017 found DWS to be significantly associated with HF symptoms in patients with AS with preserved ejection fraction (OR: 0.91, CI:0.86-0.96, P<0.005). Immediately thereafter, in 2018,Kamimura D et al (50) found both continuous and categorical DWS were independently associated with incident HF after adjustment for traditional risk factors and incident coronary artery disease (HR 1.21, 95%CI 1.04-1.41 for 0.1 decrease in continuous DWS, P= 0.014; HR 1.40, 95%CI 1.05-1.87 for the smallest DWS quintile vs other combined quintiles, P = 0.022), and in 2019 a study by Tsujimoto S, et al (51) showed low DWS ([?]…”

Section: The Epicardial Movement Index (Emi) and Diastolic Wall Strai...mentioning

confidence: 81%

Evaluation of Left Ventricular Stiffness with Echocardiography

Wang

Zhang

et al. 2023

Preprint

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Half of patients with heart failure are presented with preserved ejection fraction (HFpEF). The pathophysiology of these patients is complex but increased left ventricular (LV) stiffness is proved to play a key role. However, the application of this parameter was limited since its measurements requires invasive catheterization. With advances in ultrasound technology, new advances have been achieved in the assessment of LV chamber or myocardial stiffness using noninvasive echocardiography. Therefore, this review was carried out to summarize the pathophysiological mechanisms, correlations with invasive LV stiffness constant, applications in different populations as well as the limitations of echocardiography-derived indices for assessment of both LV chamber and myocardial stiffness. LV chamber stiffness indices such as E/e’/LVEDV, E/SRe/LVEDV, and DPVQ were derived on the basis of the relationship between echocardiographic parameters of LVFP and LV size. However, all these methods are surrogate and lumped measurements, relying on E/e’ or E/SRe for evaluating LVFP. The limitations of E/e’ or E/SRe in assessment of LVFP may contribute to the moderate correlation between E/e’/LVEDV or E/SRe/LVEDV and LV stiffness constant. Even the best validated measurement (DPVQ) is considered unreliable in the individual patient. Compared to E/e’/LVEDV and E/SRe/LVEDV, I and F may display better performance in assessing LV chamber stiffness as evidenced by a higher correlation with LV stiffness constant. However, only one study has been conducted in the literature on the exploration and application of I /I and F /F , and its accuracy in assessing LV chamber stiffness remains to be confirmed. In terms of echocardiographic indices for LV myocardial stiffness evaluation, the parameters of EMI/DWS, iVP and SWI were proposed. Despite alteration of DWS and its predictive value of adverse outcomes in various populations have been widely validated, it was found that DWS may be better considered as an overall marker of cardiac function performance instead of pure myocardial stiffness. As for the iVP and SWI, the validities of these two indices in assessing LV myocardial stiffness have not been confirmed in invasive studies. More echocardiographic indices with higher sensitivities and specificities warrant to be further uncovered to evaluate LV stiffness.

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“…Many studies attempted to identify echocardiographic parameters that would predict outcome of LG SAS with preserved LVEF. AVAi, pressure gradients, dobutamine testing and other parameters have been analyzed, but the results were not always consistent [ 26 – 30 ]. The current study also showed that the traditional echocardiographic measures for the severity of AS (AVAi and pressure gradients) were not significant in predicting all-cause mortality in LG SAS with preserved LVEF.…”

Section: Discussionmentioning

confidence: 99%

Echocardiography and EuroSCORE II for the stratification of low-gradient severe aortic stenosis and preserved left ventricular ejection fraction

Fan

Shen

Stacey

et al. 2021

Int J Cardiovasc Imaging

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The purpose of this study was to explore the utility of echocardiography and the EuroSCORE II in stratifying patients with low-gradient severe aortic stenosis (LG SAS) and preserved left ventricular ejection fraction (LVEF ≥ 50%) with or without aortic valve intervention (AVI). The study included 323 patients with LG SAS (aortic valve area ≤ 1.0 cm2 and mean pressure gradient < 40 mmHg). Patients were divided into two groups: a high-risk group (EuroSCORE II ≥ 4%, n = 115) and a low-risk group (EuroSCORE II < 4%, n = 208). Echocardiographic and clinical characteristics were analyzed. All-cause mortality was used as a clinical outcome during mean follow-up of 2 ± 1.3 years. Two-year cumulative survival was significantly lower in the high-risk group than the low-risk patients (62.3% vs. 81.7%, p = 0.001). AVI tended to reduce mortality in the high-risk patients (70% vs. 59%; p = 0.065). It did not significantly reduce mortality in the low-risk patients (82.8% with AVI vs. 81.2%, p = 0.68). Multivariable analysis identified heart failure, renal dysfunction and stroke volume index (SVi) as independent predictors for mortality. The study suggested that individualization of AVI based on risk stratification could be considered in a patient with LG SAS and preserved LVEF.

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Increased Left Ventricular Diastolic Stiffness Is Associated With Heart Failure Symptoms in Aortic Stenosis Patients With Preserved Ejection Fraction

Cited by 10 publications

References 31 publications

Novel Echocardiography-Derived Left Ventricular Stiffness Index in Low-Flow Versus Normal-Flow Severe Aortic Stenosis with Preserved Left Ventricular Ejection Fraction

Novel Echocardiography-Derived Left Ventricular Stiffness Index in Low-Flow Versus Normal-Flow Severe Aortic Stenosis with Preserved Left Ventricular Ejection Fraction

Evaluation of Left Ventricular Stiffness with Echocardiography

Echocardiography and EuroSCORE II for the stratification of low-gradient severe aortic stenosis and preserved left ventricular ejection fraction

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