Prognostic Value of Global Longitudinal Strain in Asymptomatic Aortic Stenosis: A Systematic Review and Meta-Analysis

Sex Differences in Aortic Stenosis: From the Pathophysiology to the Intervention, Current Challenges, and Future Perspectives

Calcific aortic stenosis (AS) is a major cause of morbidity and mortality in high-income countries. AS presents sex-specific features impacting pathophysiology, outcomes, and management strategies. In women, AS often manifests with a high valvular fibrotic burden, small valvular annuli, concentric left ventricular (LV) remodeling/hypertrophy, and, frequently, supernormal LV ejection fraction coupled with diastolic dysfunction. Paradoxical low-flow low-gradient AS epitomizes these traits, posing significant challenges post-aortic valve replacement due to limited positive remodeling and significant risk of patient-prosthesis mismatch. Conversely, men present more commonly with LV dilatation and dysfunction, indicating the phenotype of classical low-flow low-gradient AS, i.e., with decreased LV ejection fraction. However, these distinctions have not been fully incorporated into guidelines for AS management. The only treatment for AS is aortic valve replacement; women are frequently referred late, leading to increased heart damage caused by AS. Therefore, it is important to reassess surgical planning and timing to minimize irreversible cardiac damage in women. The integrity and the consideration of sex differences in the management of AS is critical. Further research, including sufficient representation of women, is needed to investigate these differences and to develop individualized, sex-specific management strategies.

The Relative Apical Sparing Strain Pattern in Severe Aortic Valve Stenosis: A Marker of Adverse Cardiac Remodeling

BACKGROUND

The presence of a relative apical sparing (RAS) echocardiographic strain pattern raises a suspicion of underlying cardiac amyloidosis (CA). However, it is also increasingly observed in patients with aortic stenosis (AS). We aimed to evaluate the prevalence, dynamics, and clinical characteristics of the RAS strain pattern in severe AS patients who had been referred for surgical aortic valve replacement (SAVR).

METHODS

A total of 77 patients with severe AS and without CA were included with a mean age of 70 (62-73) years, 58% female, a mean aortic valve area index of 0.45 ± 0.1 cm2/m2, and a mean gradient of 54.9 (45-70) mmHg.

RESULTS

An RAS strain pattern was detected in 14 (18%) patients. RAS-positive patients had a significantly higher LV mass index (125 ± 28 g/m2 vs. 91 ± 32, p = 0.001), a lower LV ejection fraction (62 ± 12 vs. 68 ± 13, p = 0.040), and lower global longitudinal strain (-14.9 ± 3 vs. -18.7 ± 5%, p = 0.002). RAS strain pattern-positive patients also had higher B-type natriuretic peptide (409 (161-961) vs. 119 (66-245) pg/L, p = 0.032) and high-sensitivity troponin I (15 (13-29) vs. 9 (5-18) pg/L, p = 0.026) levels. Detection of an RAS strain pattern was strongly associated with increased LV mass index (OR 1.03, 95% CI 1.01-1.06, p < 0.001). The RAS strain pattern had resolved in all patients by 3 months after SAVR.

CONCLUSIONS

Our findings suggest that the RAS strain pattern can be present in patients with severe AS without evidence of CA. The presence of an RAS strain pattern is associated with adverse LV remodeling, and it resolves after SAVR.

Prognostic Value of Cardiac Magnetic Resonance Feature Tracking Strain in Aortic Stenosis

BACKGROUND

Recent data have suggested that global longitudinal strain (GLS) could be useful for risk stratification of patients with severe aortic stenosis (AS). In this study, we aimed to investigate the prognostic role of GLS in patients with AS and also its incremental value in relation to left ventricular ejection fraction (LVEF) and late gadolinium enhancement (LGE).

METHODS

We analysed all consecutive patients with AS and LGE-CMR in our institution. Survival data were obtained from office of national statistics, a national body where all deaths in England are registered by law. Death certificates were obtained from the general register office.

RESULTS

Some 194 consecutive patients with aortic stenosis were investigated with CMR at baseline and followed up for 7.3 ± 4 years. On multivariate Cox regression analysis, only increasing age remained significant for both all-cause and cardiac mortality, while LGE (any pattern) retained significance for all-cause mortality and had a trend to significance for cardiac mortality. Kaplan-Meier survival analysis demonstrated that patients in the best and middle GLS tertiles had significantly better mortality compared to patients in the worst GLS tertiles. Importantly though, sequential Cox proportional-hazard analysis demonstrated that GLS did not have significant incremental prognostic value for all-cause mortality or cardiac mortality in addition to LVEF and LGE.

CONCLUSIONS

Our study has demonstrated that age and LGE but not GLS are significant poor prognostic indicators in patients with moderate and severe AS.

Redefining cardiac damage staging in aortic stenosis: the value of GLS and RVAc

AIMS

Cardiac damage staging has been postulated as a prognostic tool in patients undergoing transcatheter aortic valve replacement (TAVR). The aims of our study are (i) to validate cardiac damage staging systems previously described to stratify patients with aortic stenosis (AS), (ii) to identify independent risk factors for 1-year mortality in patients with severe AS undergoing TAVR, and (iii) to develop a novel staging model and compare its predictive performance to that of the above mentioned.

METHODS AND RESULTS

Patients undergoing TAVR from 2017 to 2021 were included in a single-centre prospective registry. Transthoracic echocardiography was performed in all patients before TAVR. Logistic and Cox's regression analysis were used to identify predictors of 1-year all-cause mortality. In addition, patients were classified based on previously published cardiac damage staging systems, and the predictive performance of the different scores was measured.Four hundred and ninety-six patients (mean age 82.1 ± 5.9 years, 53% female) were included. Mitral regurgitation (MR), left ventricle global longitudinal strain (LV-GLS) and right ventricular-arterial coupling (RVAc) were independent predictors of all-cause 1-year mortality. A new classification system with four different stages was developed using LV-GLS, MR, and RVAc. The area under the receiver operating characteristic curve was 0.66 (95% confidence interval 0.63-0.76), and its predictive performance was superior compared with the previously published systems (P < 0.001).

CONCLUSION

Cardiac damage staging might have an important role in patients' selection and better timing for TAVR. A model that includes LV-GLS, MR, and RVAc may help to improve prognostic stratification and contribute to better selection of patients undergoing TAVR.

Current and novel echocardiographic assessment of left ventricular systolic function in aortic stenosis-A comprehensive review

Aortic stenosis (AS) is a complex and progressive condition that can significantly reduce the quality of life and increase the incidence of premature mortality. Transthoracic echocardiography (TTE) is the gold standard imaging modality for the assessment of AS severity. While left ventricular ejection fraction (LVEF) derived from TTE is a very well-understood parameter, limitations such as high inter and intra-observer variability, insensitivity to sub-clinical dysfunction, and influence of loading conditions make LVEF a complicated and unreliable parameter. Myocardial deformation imaging has been identified as a promising parameter for identifying subclinical left ventricular dysfunction, however, this parameter is still afterload dependent. Myocardial Work is a promising novel assessment technique that accounts for afterload by combining the use of myocardial deformation imaging and non-invasive blood pressure to provide a more comprehensive assessment of mechanics beyond LVEF. This review evaluates the evidence for various echocardiographic assessment parameters used to quantify left ventricular function including myocardial work in patients with AS.

Prognostic value of global longitudinal strain in hypertrophic cardiomyopathy: A systematic review and meta-analysis

BACKGROUND

As previously reported, impairment of left ventricular global longitudinal strain (LVGLS) is associated with myocardial fibrosis, arrhythmias, and heart failure in hypertrophic cardiomyopathy (HCM) patients.

HYPOTHESIS

This study aimed to estimate the association between LVGLS measured by echocardiography and major adverse cardiovascular events (MACE) in patients with HCM.

METHODS

Pubmed, Embase, Scopus, and Cochrane Library databases were systematically searched for evaluating the difference of LVGLS between MACE and non-MACE and the relevance of LVGLS and MACE in HCM patients, mean difference (MD), and pooled hazard ratios (HR) with 95% confidence interval (CI) were calculated. Publication bias was detected by funnel plots and Egger's test, and trim-and-fill analysis was employed when publication bias existed.

RESULTS

A total of 13 studies reporting 2441 HCM patients were included in this meta-analysis. Absolute value of LVGLS was lower in the group of HCM with MACE (MD = 2.74, 95% CI: 2.50-2.99, p < .001; I²  = 0, p = .48). In the pooled unadjusted model, LVGLS was related to MACE (HR = 1.14, 95% CI: 1.06-1.22, p < .05, I²  = 58.4%, p < .01) and there is a mild heterogeneity, and sensitivity analysis showed stable results. In the pooled adjusted model, LVGLS was related to MACE (HR = 1.12, 95% CI: 1.08-1.16, p < .05; I²  = 0%, p = .442). Egger's tests showed publication bias, and trim-and-fill analysis was applied, with final results similar to the previous and still statistically significant.

CONCLUSION

The meta-analysis suggested that impaired LVGLS was associated with poor prognosis in HCM patients.

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.