Natural history of severe aortic stenosis: Diastolic wall strain as a novel prognostic marker

Abstract

Background and Aim Diastolic wall strain (DWS) has been proposed as a simple noninvasive measure of left ventricular (LV) stiffness. This study investigated DWS as a possible predictor of mortality in severe aortic stenosis (AS). Methods 138 patients with severe AS (indexed aortic valve area [AVA]<0.6 cm2/m2) and normal ejection fraction (>55%) were included. 52 patients (38%) had aortic valve interventions or poor image quality (n=5) and were excluded leaving 86 in the study group (84±8 years, 70% female, 69% African American). DWS was defined as (LVPWs−LVPWd)/LVPWs where LVPWs=left ventricular posterior wall thickness in systole and LVPWd=left ventricular wall thickness in diastole. Results Follow‐up extended 2.0±1.9 years (median 1.6 years). Mean DWS for the group was 0.21±0.11 (normal=0.4±0.07). In patients who died, DWS was significantly lower than in survivors (0.18±0.09 vs 0.24±0.11, P=.02). By contrast, traditional measures of diastolic dysfunction did not predict death. Regression analysis showed DWS predicted death even after adjusting for age, sex, race, indexed AVA, symptoms (angina, shortness of breath, dizziness, syncope), and clinical factors (creatinine, smoking, diabetes, hypertension, hyperlipidemia) (HR 2.5 [95% CI 1.02‐5.90], P<.05). The best cutoff value for DWS of 0.25 had a sensitivity of 42% and specificity of 83% for predicting death. Conclusions DWS is an independent predictor of all‐cause mortality in patients with severe AS, even after accounting for traditional clinical and echocardiographic parameters.

Evaluation of Left Ventricular Stiffness with Echocardiography

“…Immediately thereafter, Amano M et al (46) found that DWS was an independent predictor of prognosis in the diagnosis of patients with AL amyloidosis with cardiac involvement during follow-up of patients, and DWS was significantly lower in patients with poor prognosis (all-cause death and cardiac death: HR 0.93 [95% CI 0.88-0.99], P<.02). The same predictive value of DWS was shown by Obasare E et al (47) in a retrospective study of patients with severe aortic stenosis, where DWS could predict mortality independently of conventional clinical and echocardiographic parameters (HR 2.5 [95% CI 1.02-5.90], P<.05). In 2020, Kishima H et al( 48) a retrospective study of patients with PMI study showed that DWS was independently associated with AHREs (HR 0.223, 95% CI 0.137-0.357, P<0.0001), and patients with reduced DWS (<0.33) had a higher risk of incidences of AHREs.…”

“…However, the relationship between DWS and LV myocardial stiffness constant which is the gold standard to evaluate LV myocardial stiffness, was proved only in a basic experimental study and a correlation of only 0.4 does not "prove" that the LV myocardial stiffness could be accurately reflected by DWS. In addition, despite the animal study from Takeda et al proved that there was a lack of correlation between DWS and LV systolic function, wall thickness at the beginning of diastole, LV chamber size, indices derived from the transmitral flow velocity curves as well as preload alteration, recent clinical studies (43,46,47,50,53) found that DWS may not be a pure measure of diastolic function since it also correlates with systolic function. Therefore, DWS may be considered as an overall marker of cardiac performance, including systolic and diastolic mechanics.…”

Depressed systemic arterial compliance and impaired left ventricular midwall performance in aortic stenosis with concomitant type 2 diabetes: a retrospective cross-sectional study

“…In addition, aortic pulse wave velocity was independently related to pre- and post-operative NYHA class in AS subjects undergoing surgical valve replacement [49]. Nevertheless, large-scale prospective studies are warranted to assess potential clinical utility of measures of arterial stiffness or compliance, as well as novel indices of LV function, such as mwFS or recently proposed diastolic wall strain [50] in asymptomatic AS patients.…”

Evaluation of left ventricular stiffness with echocardiography

“…Additionally, while animal studies 39 have shown no correlation between DWS and LV systolic function, wall thickness at the beginning of diastole, LV chamber size, and indices derived from transmitral flow velocity curves. Recent clinical studies 12,43,46,47,49 have indicated that DWS may not solely reflect diastolic function as it also correlates with systolic function. Therefore, DWS may be considered as an overall marker of cardiac performance, encompassing both systolic and diastolic mechanics.…”