Severe aortic stenosis with preserved ejection fraction and evidence of impairment in structure, myocardial strain and ventricular function: A new contribution to clinical decision making

Hita, Alejandro; Baratta, Sergio; Vaccarino, Guillermo; Navia, José L.; Olano, D.; Telayna, Juan Manuel; Costantini, Ricardo; Chejtman, Demián; Matoso, Miriam; Gelpi, Ricardo J.; Donato, Martín; Morales, Celina

doi:10.5603/cj.a2015.0034

Cited by 4 publications

(4 citation statements)

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“…This further supports our hypothesis that the mechanism of worse prognosis of patients with PAD >29.3 mm is associated also with less LV recovery despite the successful AV replacement [19]. AoD indexed to body surface area (BSA; a measure of body size) appears a more patient-specific predictor of the risk of serious events than uncorrected AoD [19]. However, moderate or higher risk of subsequent events (≥8%/year) was seen with AoD <55.0 mm only among a few female subjects with height <150 cm.…”

Section: Discussionsupporting

confidence: 89%

“…Current results are in line with the prior observations linking dilatated PAD with features of more advanced and complex baseline LV dysfunction (abnormal myocardial structure with diastolic and systolic impairment) as signified by more frequent and longer AF history (more stroke/TIA complications) [18] and lower LVEF and baseline AV gradients. This further supports our hypothesis that the mechanism of worse prognosis of patients with PAD >29.3 mm is associated also with less LV recovery despite the successful AV replacement [19]. AoD indexed to body surface area (BSA; a measure of body size) appears a more patient-specific predictor of the risk of serious events than uncorrected AoD [19].…”

Section: Discussionsupporting

confidence: 79%

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Prognostic value of computed tomography derived measurements of pulmonary artery diameter for long-term outcomes after transcatheter aortic valve replacement

et al. 2022

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Background: An increase in pulmonary artery diameter (PAD) on multi-detector computed tomography (MDCT) may indicate pulmonary hypertension. We assessed the prognostic value of MDCT-derived measurements of PAD on outcomes after successful transcatheter aortic valve replacement (TAVR).Methods: Consecutive patients treated with TAVR from February 2013 to October 2017, with a 68.8% rate of new generation valves, underwent pre-interventional MDCT with measurements of PAD (in the widest short-axis within 3 cm of the bifurcation) and ascending aortic diameter (AoD; at the level of the PAD). The PAD/AoD ratio was calculated. Patients with high-density lipoprotein cholesterol levels ≤46 mg/dl and C-reactive protein levels ≥0.20 mg/dl at baseline were identified as the frail group. One-year mortality was established for all subjects.Results: Among studied 266 patients (median age, 82.0 years; 63.5% women) those who died at 1 year (n = 34; 12.8%) had larger PAD and PAD/AoD (28.9 [5.0] vs. 26.5 [4.6] mm and 0.81 [0.13] vs. 0.76 [0.13] mm vs. the rest of the studied subjects; P = 0.005 and P = 0.02, respectively) but similar AoD. The cutoff value for the PAD to predict 1-year mortality was 29.3 mm (sensitivity, 50%; specificity, 77%; area under the curve, 0.65). Patients with PAD >29.3 mm (n = 72; 27%) had higher 1-year mortality (23.6% vs. 8.8%, log-rank P = 0.001). Baseline characteristics associated with PAD >29.3 mm were a bigger body mass index, more frequent diabetes mellitus, more prior stroke/transient ischemic attacks and atrial fibrillation, and lower baseline maximal aortic valve gradient with higher pulmonary artery systolic pressure (PASP). PAD >29.3 mm and frailty, but not baseline PASP, remained predictive of 1-year mortality in the multivariable model (hazard ratio [HR], 2.221; 95% CI, 1.038-4.753; P = 0.04 and HR, 2.801; 95% CI, 1.328-5.910; P = 0.007, respectively).Conclusion: PAD >29.3 mm on baseline MDCT is associated with higher 1-year mortality after TAVR, independently of echocardiographic measures of PH and frailty.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionsupporting

confidence: 79%

Prognostic value of computed tomography derived measurements of pulmonary artery diameter for long-term outcomes after transcatheter aortic valve replacement

et al. 2022

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“…However, LVEF has several well know limitation. Longitudinal global strain (LGS) is more sensible to assess subclinical changes in LV function even in patients with preserved LVEF [7]. More recently, multilayer longitudinal strain (LS) has emerged as an innovative tool for a more detailed evaluation of LV mechanics providing a separate analysis in different myocardial layers.…”

Section: Introductionmentioning

confidence: 99%

Myocardial contractility recovery following acute pressure unloading after transcatheter aortic valve intervention (TAVI) in patients with severe aortic stenosis and different left ventricular geometry: a multilayer longitudinal strain echocardiographicanalysis

Cimino

Monosilio

Luongo

et al. 2020

Int J Cardiovasc Imaging

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Aim of the present study was to describe the left ventricular longitudinal strain (LS) in all myocardial layers in patients with severe aortic stenosis (AS), preserved left ventricular ejection fraction (LVEF) in different LV geometry and to compare LS analysis before and early after acute LV unloading provided by transcatheter aortic valve implantation (TAVI). 68 patients were enrolled. LS was measured from the endocardial layer (Endo-LS), epicardial layer (Epi-LS) and full thickness of myocardium (Transmural-LS) before and after TAVI. Patients were divided in two groups accordingly with relative wall thickness (RWT): concentric LV hypertrophy (cLVH) vs eccentric LV hypertrophy (eLVH). Less impaired values of LS at baseline were observed, in all layers, in patients with cLVHas compared to patients with eLVH (Endo-LS was − 13.2 ± 2 vs − 11.1±3 %, p = 0.041; Epi-LS was − 11.8 ± 1.8 vs − 9.9 ± 3 %, p = 0.043; Transmural-LS was − 12.3 ± 1.8 vs − 10.49 ± 3.3 %, p = 0.02, respectively). A significant improvement in endocardial LS (Endo-LS) after TAVI was detected only in cLVH(− 13 ± 2 vs − 14 ± 2, p = 0.011). Our findings documented that concentric LVH had better basal strain function and showed a better myocardial recovery after TAVI compared to eLVH.

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“…As the LV faces an increasing load from the fixed valve obstruction, it is critical that a decline in LV systolic function is not missed. Once missed, the risk of intervention for severe AS rises sharply.In the present study, Hita et al [5] demonstrate the use of LV diastolic function and increase in LV end-diastolic pressure (LVEDP) as markers of LV systolic function decline in patients with symptomatic AS. Twenty-six symptomatic patients with severe AS were evaluated prior to cardiovascular surgery with echocardiography and invasive catheterization.…”

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confidence: 99%

Aortic stenosis evaluation: Novel tools to define the complexity

Pal

2015

Cardiol J.

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Aortic valve stenosis (AS) is the most common valvular disease pathology in developed countries affecting over 5% of the population over the age of 75 [1]. Age is also the most significant risk factor in the development of aortic stenosis. As the global population ages [2], AS rates will continue to increase around the world. Some of the challenges that have surfaced in AS management are appropriate diagnosis of stenosis severity and timing of intervention. Patients who develop severe AS are monitored closely for the development of symptoms or the development of left ventricle (LV) function decline. International guidelines [3,4] currently recommend intervention for severe AS once symptoms develop or when there is a decline in LV ejection fraction (LVEF). As the LV faces an increasing load from the fixed valve obstruction, it is critical that a decline in LV systolic function is not missed. Once missed, the risk of intervention for severe AS rises sharply.In the present study, Hita et al. [5] demonstrate the use of LV diastolic function and increase in LV end-diastolic pressure (LVEDP) as markers of LV systolic function decline in patients with symptomatic AS. Twenty-six symptomatic patients with severe AS were evaluated prior to cardiovascular surgery with echocardiography and invasive catheterization. Patients with normal LVEDP (less than 15 mm Hg) were compared to patients with elevated LVEDP (over 15 mm Hg). Patients with elevated LVEDP were further subdivided into without coronary artery disease (CAD) or with CAD. Their data show that patients with increased LVEDP also had LV stiffness, measured as a ratio of LV pressure to LV end diastolic volume, and lower systolic longitudinal strain. They also showed that these hemodynamic changes were associated with histologic changes including a higher myocyte cross sectional and collagen volume. These findings suggest that severe AS with compensated LV function, defined by normal LVEDP, is hemodynamically and structurally different from decompensated severe AS.This work has limitations including the small patient sample size. The study had 26 patients with 7 patients in two groups and 12 in the third group. Further, there were significant differences in the aortic valve gradient between the groups, which may independently account for the differences observed in LVEDP and LV stiffness or diastolic function.This paper supports the concept that using LVEF to monitor LV systolic function may be too blunt a tool to guide the timing of intervention for severe AS. This study's findings are in keeping with the work of other researchers who have proposed the use of 2-dimensional (2D) longitudinal LV strain [6,7] as a marker of future systolic dysfunction, in patients with severe AS, when LVEF is still preserved. Early identification of declining LV function is an important concern that is necessary in many areas of current medical care. These findings may be generalized to the monitoring of LV function in a wide range of conditions such as other valvular heart disease, like ...

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Severe aortic stenosis with preserved ejection fraction and evidence of impairment in structure, myocardial strain and ventricular function: A new contribution to clinical decision making

Cited by 4 publications

References 50 publications

Prognostic value of computed tomography derived measurements of pulmonary artery diameter for long-term outcomes after transcatheter aortic valve replacement

Prognostic value of computed tomography derived measurements of pulmonary artery diameter for long-term outcomes after transcatheter aortic valve replacement

Myocardial contractility recovery following acute pressure unloading after transcatheter aortic valve intervention (TAVI) in patients with severe aortic stenosis and different left ventricular geometry: a multilayer longitudinal strain echocardiographicanalysis

Aortic stenosis evaluation: Novel tools to define the complexity

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