Distribution and prognostic value of left ventricular global longitudinal strain in elderly patients with symptomatic severe aortic stenosis undergoing transcatheter aortic valve replacement

Multidirectional myocardial function in bicuspid aortic valve stenosis patients: a three-dimensional speckle tracking analysis

Purpose

The impact of aortic stenosis (AS) severity on multidirectional myocardial function in patients with bicuspid aortic valve (BAV) remains unclear, despite the recognized presence of early left ventricular longitudinal myocardial dysfunction in BAV patients with normal valve function. The aim of the study was to evaluate the multidirectional myocardial functions of BAV patients.

Methods

A total of 86 BAV patients (age 46.71 ± 13.62 years, 69.4% men) with normally functioning (BAV-nf), mild AS, moderate AS, and severe AS with preserved left ventricular ejection fraction (LVEF ≥ 52%) were included. 30 healthy volunteers were recruited as the control group. Multidirectional strain and volume analysis were performed by three-dimensional speckle tracking echocardiography(3D-STE).

Results

Global longitudinal strain (GLS), and global radial strain (GRS) were reduced in BAV-nf patients compared with the controls. With each categorical of AS severity from BAV-nf to severe AS, there was an associated progressive impairment of GLS and GRS (all P < 0.001). Global circumferential strain (GCS) did not show a significant decrease from BAV-nf to mild AS but began to decrease from moderate AS. Multiple linear regressions indicated that indexed aortic valve area (AVA/BSA), as a measure of AS severity, was an independent determinant of GLS, GCS and GRS.

Conclusions

Left ventricular longitudinal myocardial reduction is observed even in patients with well-functioning bicuspid aortic valves. With each categorical increase in the grade of AS severity from normally functioning to severe aortic stenosis, there was an associated progressive impairment of longitudinal myocardial function. Furthermore, circumferential myocardial function was starting damaged from moderate AS. AVA/BSA was independently associated with multidirectional myocardial function injuries.

Changes and Prognostic Implications of Myocardial Work in Aortic Stenosis Subtypes Undergoing Transcatheter Valve Implantation

Background

Evaluation of left ventricle (LV) systolic function in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) is challenging, as LV ejection fraction (LVEF) and global longitudinal strain are afterload dependent. LV global work indices (GWIs) estimate the afterload corrected systolic function.

Objectives

The purpose of this study was to evaluate changes in and prognostic implications of GWIs in subtypes of AS patients before and 1 month after TAVI.

Methods

We included 473 patients undergoing TAVI. GWI was estimated using strain imaging and by adding the aortic valve mean gradient to the systolic blood pressure. The primary endpoint was all-cause mortality, evaluated by Cox proportional hazards and Kaplan-Meier curves.

Results

High gradient, low flow/low gradient, and normal flow/low gradient AS was found in 48%, 27%, and 25%. In patients with LVEF ≥50% delta GWI decreased from preoperative assessment to 1-month follow-up across all subtypes; high gradient (-353 ± 589 mm Hg%, P < 0.01), low flow/low gradient (-151 ± 652 mm Hg%, P = 0.13), and normal flow/low gradient (-348 ± 606 mm Hg%, P < 0.01). For patients with LVEF <50% delta GWI increased; high gradient 127 ± 491 mm Hg%, P = 0.05; low flow/low gradient 106 ± 510 mm Hg%, P = 0.06; normal flow/low gradient 107 ± 550 mm Hg%, P < 0.27. The median follow-up time was 60 months (IQR: 45-69 months). Each step of 100 mm Hg% higher GWI at pre-TAVI assessment was associated with a reduction in all-cause mortality in multivariable analysis (HR: 0.96 [95% CI: 0.92-1.00], P = 0.033).

Conclusions

GWI increases in patients with reduced LVEF after TAVI across AS subtypes whereas GWI decreases in patients with preserved LVEF. Assessment of GWI offers additional prognostic implications beyond LVEF and global longitudinal strain.

Shifting from Left Ventricular Ejection Fraction to Strain Imaging in Aortic Stenosis

Adverse ventricular remodeling is an inflexion point of disease progression in aortic stenosis (AS) and a major determinant of prognosis. Intervention before irreversible myocardial damage is of paramount importance to sustain favorable post-operative outcomes. Current guidelines recommend a left ventricular ejection fraction (LVEF)-based strategy to determine the threshold for intervention in AS. However, LVEF has several pitfalls: it denotes the left ventricular cavity volumetric changes and it is not suited to detecting subtle signs of myocardial damage. Strain has emerged as a contemporary imaging biomarker that describes intramyocardial contractile force, providing information on subclinical myocardial dysfunction due to fibrosis. A large body of evidence advocates its use to determine the switch from adaptive to maladaptive myocardial changes in AS, and to refine thresholds for intervention. Although mainly studied in echocardiography, studies exploring the role of strain in multi-detector row computed tomography and cardiac magnetic resonance are emerging. This review, therefore, summarizes contemporary evidence on the role of LVEF and strain imaging in AS prognosis, aiming to move from an LVEF-based to a strain-based approach for risk stratification and therapeutic decision-making in AS.

Prognostic Value of Preprocedural LV Global Longitudinal Strain for Post-TAVR-Related Morbidity and Mortality: A Meta-Analysis

BACKGROUND

Left ventricular ejection fraction (LVEF) demonstrates limited prognostic value for post-transcatheter aortic valve replacement (TAVR) outcomes. Evidence regarding the potential role of left ventricular global longitudinal strain (LV-GLS) in this setting is inconsistent.

OBJECTIVES

The aim of this systematic review and meta-analysis of aggregated data was to evaluate the prognostic value of preprocedural LV-GLS for post-TAVR-related morbidity and mortality.

METHODS

The authors searched PubMed, Embase, and Web of Science for studies investigating the association between preprocedural 2-dimensional speckle-tracking-derived LV-GLS and post-TAVR clinical outcomes. An inversely weighted random effects meta-analysis was adopted to investigate the association between LV-GLS vs primary (ie, all-cause mortality) and secondary (ie, major cardiovascular events [MACE]) post-TAVR outcomes.

RESULTS

Of the 1,130 identified records, 12 were eligible, all of which had a low-to-moderate risk of bias (Newcastle-Ottawa scale). On average, 2,049 patients demonstrated preserved LVEF (52.6% ± 1.7%), but impaired LV-GLS (-13.6% ± 0.6%). Patients with a lower LV-GLS had a higher all-cause mortality (pooled HR: 2.01; 95% CI: 1.59-2.55) and MACE (pooled odds ratio [OR]: 1.26; 95% CI: 1.08-1.47) risk compared with patients with higher LV-GLS. In addition, each percentage point decrease of LV-GLS (ie, toward 0%) was associated with an increased mortality (HR: 1.06; 95% CI: 1.04-1.08) and MACE risk (OR: 1.08; 95% CI: 1.01-1.15).

CONCLUSIONS

Preprocedural LV-GLS was significantly associated with post-TAVR morbidity and mortality. This suggests a potential clinically important role of pre-TAVR evaluation of LV-GLS for risk stratification of patients with severe aortic stenosis. (Prognostic value of left ventricular global longitudinal strain in patients with aortic stenosis undergoing Transcatheter Aortic Valve Implantation: a meta-analysis; CRD42021289626).

Prognostic implications of residual left ventricular hypertrophy and systolic dysfunction in aortic stenosis following transcatheter aortic valve replacement

The impact of left ventricle (LV) hypertrophy (LVH) regression on contractility-associated measures, the extent of residual cardiac dysfunction and prognostic implications after the initial remodeling process after transcatheter aortic valve replacement (TAVR) has not been investigated. We aimed to assess whether greater LV mass regression from pre-TAVR to 12-months after TAVR was associated with increased systolic function; and assess the prognostic value of residual LVH, systolic function and contractility-associated measures 12-months after TAVR. A total of 439 symptomatic patients were included and examined by echocardiography. LVH regression was assessed as percentage change in LV mass index (LVMi) from baseline to 12-months after TAVR. Midwall fractional shortening (mFS) and stress-corrected (SC-mFS) were used as contractility-associated measures. Primary outcome was all-cause mortality. SC-mFS increased from 0.94 (0.7) at baseline (BS) to 1.22 (0.7) (p < 0.05) 12-months after TAVR for patients with the most LVH regression, compared to patients with no LV regression (BS 1.06 (0.7) to 1.04 (0.5), NS). At 12-months after TAVR, multivariate analysis showed independent prognostic value of LVEF < 50% or GLS < 15% (HR 1.59, p = 0.049) and mFS < 14% (HR 1.99, p = 0.002) for future all cause death. LVH regression in AS after TAVR is associated with significant improvements of LV systolic function in contrast to patients without LV regression. Residual LVH and subsequent LV systolic dysfunction is substantial 12 months after TAVR and are associated with reduced survival. Impaired mFS and the combination of abnormal LVEF or GLS independently predicted all-cause mortality beyond 12 months after TAVR.

Statins and Mortality of Patients After Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-analysis

While TAVI is widely used, optimal medical therapy to reduce the mortality rate after transcatheter aortic valve implantation (TAVI) is still unclear. We performed a systematic review and meta-analysis to evaluate the impact of statins on mortality following TAVI. Present systematic review of the literature was performed using Medline, Embase, Scopus, and Web of Science; all studies reported all-cause mortality in patients who underwent TAVI and received or did not receive statin therapy. Data were analyzed using random-effects models. Seventeen articles (21 380 patients) were included in the meta-analysis. Statin therapy was associated with a reduction of all-cause mortality (Hazard ratio [HR] = .78, 95% Confidence interval [CI] .68-.89, P < .001). Moderate between-study heterogeneity was observed (I² = 45.2). High-intensity statin therapy was more effective than low or moderate intensity statin therapy in reduction of all-cause mortality (Risk ratio [RR] = .62, 95% CI 0.45-.85, P = .003, I² = .0). Statin therapy could reduce the mid-term all-cause mortality rate following TAVI. However, all included studies were observational and, therefore, randomized controlled trials are still needed to assess the effect of statin therapy on mortality after TAVI.

Prognostic value of ventricular longitudinal strain in patients undergoing transcatheter aortic valve replacement: A systematic review and meta-analysis

Introduction

Strain obtained by speckle tracking echocardiography (STE) can detect subclinical myocardial impairment due to myocardial fibrosis (MF) and is considered a prognostic marker. Aortic stenosis (AS) is not only a valve disease, but also a cardiomyopathy characterized by MF. The purpose of this study was to systematically review and analyze ventricular strain as a predictor of adverse outcomes in patients with AS undergoing transcatheter aortic valve replacement (TAVR).

Methods

PubMed, Embase, and the Cochrane library were searched for studies that investigated the prognostic value of impaired ventricular strain on patients with AS undergoing TAVR with all-cause mortality (ACM) and major adverse cardiovascular events (MACE). Pooled odds ratios (ORs), hazard ratios (HRs), and 95% confidence intervals (CIs) were calculated to assess the role of left (LVLS) and right (RVLS) ventricular longitudinal strain in the prognostic prediction of patients with AS undergoing TAVR. Sensitivity and subgroup analysis was performed to assess heterogeneity.

Results

Twelve studies were retrieved from 571 citations for analysis. In total, 1,489 patients with a mean age of 82 years and follow-up periods varying between 1 year and 8.5 years were included. Meta-analysis showed the impaired LVLS from eight studies was associated with an increased risk for combined ACM and MACE (OR: 1.08, 95% CI: 1–1.16; p = 0.037), and ACM alone (HR: 1.08, 95% CI: 1.01–1.16; p = 0.032). Impaired RVLS from four studies was associated with an increased risk of combined ACM and MACE (OR: 1.08, 95% CI: 1.02–1.14; p < 0.01), and ACM alone (HR: 1.07, 95% CI: 1.02–1.12; p < 0.01).

Conclusions

This meta-analysis demonstrated that ventricular strain, including LVLS and RVLS, had a substantial prognostic value in ACM or combined ACM and MACE, which could be used as a valid marker for risk stratification in patients with AS undergoing TAVR.

Cardiac Magnetic Resonance Imaging Right Ventricular Longitudinal Strain Predicts Mortality in Patients Undergoing TAVI

Background: Right ventricular (RV) function predicts survival in numerous cardiac conditions, including left heart disease. The reference standard for non-invasive assessment of RV function is cardiac magnetic resonance imaging (CMR). The aim of this study was to investigate the association between pre-procedural CMR-derived RV functional parameters and mortality in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods: Patients scheduled for TAVI were recruited to undergo pre-procedural CMR. Volumetric function and global longitudinal and circumferential strain (GLS and GCS) of the RV and left ventricle (LV) were measured. The association with the primary endpoint (1-year all-cause mortality) was analyzed with Cox regression.

Results: Of 133 patients undergoing CMR, 113 patients were included in the analysis. Mean age was 81.8 ± 5.8 years, and 65% were female. Median follow-up was 3.9 [IQR 2.3–4.7] years. All-cause and cardiovascular mortality was 14 and 12% at 1 year, and 28 and 20% at 3 years, respectively. One-year all-cause mortality was significantly predicted by RV GLS [HR = 1.109 (95% CI: 1.023–1.203); p = 0.012], RV ejection fraction [HR = 0.956 (95% CI: 0.929–0.985); p = 0.003], RV end-diastolic volume index [HR = 1.009 (95% CI: 1.001–1.018); p = 0.025], and RV end-systolic volume index [HR = 1.010 (95% CI: 1.003–1.017); p = 0.005]. In receiver operating characteristic (ROC) analysis for 1-year all-cause mortality, the area under the curve was 0.705 (RV GLS) and 0.673 (RV EF). Associations decreased in strength at longer follow-up. None of the LV parameters was associated with mortality.

Conclusions: RV function predicts intermediate-term mortality in TAVI patients while LV parameters were not associated with outcomes. Inclusion of easily obtainable RV GLS may improve future risk scores.