Pre-Procedural Right Ventricular Longitudinal Strain and Post-Procedural Tricuspid Regurgitation Predict Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI)

Prognostic value of right ventricular free-wall longitudinal strain in aortic stenosis: A systematic review and meta-analysis

BACKGROUND

Assessment of right ventricular (RV) function in aortic stenosis (AS) may improve risk stratification. However, whether the prognostic value of RV free-wall longitudinal strain (RVfwLS) is better than that of other right heart or pulmonary circulation parameters remains uncertain. This study assessed and compared the prognostic value of RVfwLS with traditional parameters in the AS population using a systematic review and meta-analysis.

METHODS

We selected studies reporting the hazard ratio (HR) of RVfwLS in patients with AS. We also collected data regarding the HR of systolic pulmonary arterial pressure (SPAP), fractional area change (FAC), and tricuspid annulus plane systolic excursion (TAPSE). To ensure comparability, we standardized the HR using within-study standard deviations. The comparison between the prognostic value of RVfwLS and other parameters was conducted as a ratio of HR.

RESULTS

This meta-analysis included 9 studies comprising a total of 2547 patients, with 679 events. The pooled HR of RVfwLS was 1.56 (95 % CI: 1.39-1.75, p < 0.001). When examining the ratio of HR between RVfwLS and conventional parameters, all comparisons were statistically non-significant [RVfwLS/SPAP: 1.28 (95 % CI: 0.99-1.65, p = 0.06); RVfwLS/FAC: 1.24 (95 % CI: 0.90-1.72, p = 0.14); and RVfwLS/TAPSE:1.07 (95 % CI: 0.75-1.52, p = 0.60)].

CONCLUSIONS

This meta-analysis establishes a substantial association between RVfwLS and adverse outcomes in the AS population. However, comparative analysis between RVfwLS and SPAP, FAC, or TAPSE did not support the prognostic superiority of RVfwLS.

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.

Right vs. left ventricular longitudinal strain for mortality prediction after transcatheter aortic valve implantation

Introduction

This study aims at exploring biventricular remodelling and its implications for outcome in a representative patient cohort with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI).

Methods and results

Pre-interventional echocardiographic examinations of 100 patients with severe AS undergoing TAVI were assessed by speckle tracking echocardiography of both ventricles. Association with mortality was determined for right ventricular global longitudinal strain (RVGLS), RV free wall strain (RVFWS) and left ventricular global longitudinal strain (LVGLS). During a median follow-up of 1,367 [959-2,123] days, 33 patients (33%) died. RVGLS was lower in non-survivors [-13.9% (-16.4 to -12.9)] than survivors [-17.1% (-20.2 to -15.2); P = 0.001]. In contrast, LVGLS as well as the conventional parameters LV ejection fraction (LVEF) and RV fractional area change (RVFAC) did not differ (P = ns). Kaplan-Meier analyses indicated a reduced survival probability when RVGLS was below the -14.6% cutpoint (P < 0.001). Lower RVGLS was associated with higher mortality [HR 1.13 (95% CI 1.04-1.23); P = 0.003] independent of LVGLS, LVEF, RVFAC, and EuroSCORE II. Addition of RVGLS clearly improved the fitness of bivariable and multivariable models including LVGLS, LVEF, RVFAC, and EuroSCORE II with potential incremental value for mortality prediction. In contrast, LVGLS, LVEF, and RVFAC were not associated with mortality.

Discussion

In patients with severe AS undergoing TAVI, RVGLS but not LVGLS was reduced in non-survivors compared to survivors, differentiated non-survivors from survivors, was independently associated with mortality, and exhibited potential incremental value for outcome prediction. RVGLS appears to be more suitable than LVGLS for risk stratification in AS and timely valve replacement.

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.