Prognostic Significance of Valvuloarterial Impedance and Left Ventricular Longitudinal Function in Asymptomatic Severe Aortic Stenosis Involving Three-Cuspid Valves

Zito, Concetta; Salvia, Josephal; Cusmà-Piccione, Maurizio; Antonini‐Canterin, Francesco; Lentini, Salvatore; Oreto, Giuseppe; Bella, Gianluca Di; Montericcio, Vincenzo; Carerj, Scipione

doi:10.1016/j.amjcard.2011.06.070

Cited by 61 publications

(49 citation statements)

References 25 publications

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“…Both longitudinal strain and strain rate are severely impaired in patients with LFAS, and the extent of impairment of myocardial strain in these patients seems to be more pronounced than what has been previously reported in patients with other cardiac diseases. [6][7][8][9]11,12,16,[29][30][31][32] Assessment of 2-dimensional strain parameters during stress provided significant incremental prognostic information.…”

Section: Discussionmentioning

confidence: 99%

Two-Dimensional Strain for the Assessment of Left Ventricular Function in Low Flow–Low Gradient Aortic Stenosis, Relationship to Hemodynamics, and Outcome

Bartko

Heinze

Graf

et al. 2013

Circ: Cardiovascular Imaging

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Background-Decision making in patients with low flow-low gradient aortic stenosis mainly depends on the actual stenosis severity and left ventricular function, which is of prognostic importance. We used 2-dimensional strain parameters measured by speckle tracking at rest and during dobutamine stress echocardiography to document the extent of myocardial impairment, its relationship with hemodynamic variables, and its prognostic value. Methods and Results-In 47 patients with low flow-low gradient aortic stenosis, global peak systolic longitudinal strain (PLS) and peak systolic longitudinal strain rate (PLSR) were analyzed. PLS and PLSR at rest and peak stress were −7.56±2.34% and −7.41±2.89% (P=NS) and −0.38±0.12 s −1 and −0.53±0.18 s −1 (P<0.001), respectively. PLS and PLSR inversely correlated with left ventricular ejection fraction at rest (r s =−0.52; P<0.0001 and −0.38; P=0.008) and peak stress (r s =−0.39; P=0.007 and −0.45; P=0.002). The overall 2-year survival rate was 60%. Univariate predictors of survival were peak stress left ventricular ejection fraction (P=0.0026), peak stress PLS (P=0.0002), peak stress PLSR (P<0.0001), and N-terminal pro-B-type natriuretic peptide (P<0.0001). Three hierarchically nested multivariable Cox regression models were constructed-model 1: The Society of Thoracic Surgeons score as an indicator of clinical risk (area under the receiver operating characteristic=0.59); model 2: model 1+N-terminal pro-B-type natriuretic peptide and peak stress left ventricular ejection fraction (area under the receiver operating characteristic=0.83; incremental P<0.0001); model 3: model 2+peak stress PLSR (area under the receiver operating characteristic=0.89; incremental P=0.035). Key Words: aortic stenosis ◼ Doppler echocardiography ◼ heart failure ◼ low flow ◼ myocardial strain ◼ stress echocardiography Conclusions-In

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Section: Discussionmentioning

confidence: 99%

Two-Dimensional Strain for the Assessment of Left Ventricular Function in Low Flow–Low Gradient Aortic Stenosis, Relationship to Hemodynamics, and Outcome

Bartko

Heinze

Graf

et al. 2013

Circ: Cardiovascular Imaging

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“…31 Despite the absence of symptoms and a normal LVEF, patients with severe AS have an increased Zva. 33 In addition, this increased global afterload seems closely related to preclinical myocardial changes, identifiable by 2-dimensional strain, independent of the AS severity. This indicates that LV mechanics is affected both by the arterial and the valvular load.…”

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confidence: 99%

Association of Myocardial Deformation With Outcome in Asymptomatic Aortic Stenosis With Normal Ejection Fraction

Yingchoncharoen

Gibby

Rodriguez

et al. 2012

Circ: Cardiovascular Imaging

161

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Background-Current guidelines recommend intervention for symptomatic aortic stenosis, but the management of asymptomatic aortic stenosis remains controversial. As left ventricular global longitudinal strain (GLS) has been shown to predict cardiovascular outcome, we sought to find whether its use could guide the assessment of risk in these patients. Methods and Results-We prospectively followed 79 patients with severe asymptomatic aortic stenosis (39 men; mean age, 77 ± 12 years; aortic valve [AV] area index, 0.36 cm 2 /m 2 ). In addition to standard echocardiography, speckle strain was measured to assess GLS. Patients were followed for cardiac death and AV replacement driven by symptom development. A multivariable Cox regression was performed to identify associations with events. During 23 ± 20 months, 3 patients had cardiac death and 49 underwent AV replacement. Event-free survival was 72 ± 5% at 1 year, 50 ± 5% at 2 years, and 24 ± 5% at 4 years. Death and AV replacement were predicted by GLS (hazard ratio [HR] Methods Patient SelectionThe study population included patients with severe AS who were studied in our echocardiography laboratory from March 2004 to August 2010. Severe AS was defined as AV area <1 cm 2 or transaortic jet velocity >4 m/s. Patients were excluded if they had any additional hemodynamically significant valvular lesions, presented with symptoms (angina, dyspnea, or syncope) or LV ejection fraction (LVEF)<50%. After these exclusions, we enrolled 79 patients (39 men; 77 ± 12 years; AV area index, 0.36 cm 2 ). The protocol was approved by the institutional review board of the Cleveland Clinic. Clinical CharacteristicsClinical data were entered prospectively into an electronic health record, including age, sex, height, weight, history of coronary artery disease (previous positive coronary angiogram or stress test), history of diabetes mellitus (fasting blood glucose >126 mg/dL on 2 occasions or patients currently receiving treatment for diabetes mellitus), history of hypercholesterolemia (total cholesterol >190 mg/dL or patients receiving lipid lowering agents), history of hypertension (blood pressure ≥140/90 mm Hg or patients receiving antihypertensive drugs) were collected at baseline. The Society of Thoracic Surgeons (STS) Predicted Risk of Morbidity or Mortality (STS-PRMM) for AV procedures was calculated by entering patient data into an online STS risk calculator (http://riskcalc.sts.org/ STSWebRiskCalc273/). The STS-PRMM uses 24 variables of >50 total risk factors collected by algorithm to predict mortality for valve procedures. 17 EchocardiographyPatients underwent a standard echocardiogram performed by experienced echocardiographers, using commercially available ultrasound systems. The LV dimensions, wall thickness, and outflow tract diameter were measured according to the recommendations of the American Society of Echocardiography. 18 The degree of calcification of the AV was scored as: (1) no calcification; (2) mildly calcified (small isolated foci); (3) moderately calcified (multipl...

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“…In one prior study of 79 patients with severe asymptomatic AS it was demonstrated that LV‐GLS and Zva were both independently associated with survival at a mean of 23 months follow‐up 18. Also, in 2 other small prior studies totaling 222 asymptomatic patients with severe AS, it was demonstrated that Zva and LV‐GLS were both independently associated with a combined end point of AS symptoms, AVR, or death 17, 19. Despite similar findings in these 3 prior reports, each was limited by small sample size, lack of exercise testing data, and longer‐term follow‐up.…”

Section: Discussionmentioning

confidence: 97%

“…Prior studies have also focused on Zva and LV‐GLS to understand whether subtle changes in LV load and LV systolic performance can identify patients who will soon develop symptoms or cardiac events because of progressive AS with hemodynamic consequence impacting LV function 17, 18, 19. In one prior study of 79 patients with severe asymptomatic AS it was demonstrated that LV‐GLS and Zva were both independently associated with survival at a mean of 23 months follow‐up 18.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, exercise‐induced drop in systolic blood pressure is a Class IIa indication for surgery1, 2 However, these recommendations are based upon multiple small reports with heterogeneous end points3, 9, 10, 11, 12, 13, 14, 15 In a recent study, we have demonstrated that in asymptomatic patients with severe AS and preserved left ventricular ejection fraction (LVEF), only 50% achieved 100% of age‐sex predicted exercise capacity; with exercise stress testing providing significant reclassification of longer‐term mortality risk16 In the past decade, novel echo parameters including reduced left ventricular global longitudinal strain (LV‐GLS)17, 18, 19 and valvuloarterial impedance (Zva)17, 19, 20 have also been associated with worse prognosis in patients with asymptomatic severe AS. However, no study has systematically evaluated the incremental prognostic impact of resting Zva and LV‐GLS on data obtained from exercise stress testing in patients with asymptomatic severe AS and preserved LVEF.…”

Section: Introductionmentioning

confidence: 99%

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Outcomes in Asymptomatic Severe Aortic Stenosis With Preserved Ejection Fraction Undergoing Rest and Treadmill Stress Echocardiography

Huded

Masri

Kusunose

et al. 2018

JAHA

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BackgroundIn asymptomatic patients with severe aortic stenosis and preserved left ventricular ejection fraction, we sought to assess the incremental prognostic value of resting valvuloarterial impedence (Zva) and left ventricular global longitudinal strain (LV‐GLS) to treadmill stress echocardiography.Methods and ResultsWe studied 504 such patients (66±12 years, 78% men, 32% with coronary artery disease who underwent treadmill stress echocardiography between 2001 and 2012. Clinical and exercise variables (% of age‐sex predicted metabolic equivalents [%AGP‐METs]) were recorded. Resting Zva ([systolic arterial pressure+mean aortic valve gradient]/[LV‐stroke volume index]) and LV‐GLS (measured offline using Velocity Vector Imaging, Siemens) were obtained from the baseline resting echocardiogram. Death was the primary outcome. There were no major adverse cardiac events during treadmill stress echocardiography. Indexed aortic valve area, Zva, and LV‐GLS were 0.46±0.1 cm2/m2, 4.5±0.9 mm Hg/mL per m2 and −16±4%, respectively; only 50% achieved >100% AGP‐METs. Sixty‐four percent underwent aortic valve replacement. Death occurred in 164 (33%) patients over 8.9±3.6 years (2 within 30 days of aortic valve replacement). On multivariable Cox survival analysis, higher Society of Thoracic Surgeons score (hazard ratio or HR 1.06), lower % AGP‐METS (HR 1.16), higher Zva (HR 1.25) and lower LV‐GLS (HR 1.12) were associated with higher longer‐term mortality, while aortic valve replacement (HR 0.45) was associated with improved survival (all P<0.01). Sequential addition of ZVa and LV‐GLS to clinical model (Society of Thoracic Surgeons score and %AGP‐METs) increased the c‐statistic from 0.65 to 0.69 and 0.75, respectively, both P<0.001); findings were similar in the subgroup of patients who underwent aortic valve replacement.ConclusionsIn asymptomatic patients with severe aortic stenosis undergoing treadmill stress echocardiography, LV‐GLS and ZVa offer incremental prognostic value.

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Prognostic Significance of Valvuloarterial Impedance and Left Ventricular Longitudinal Function in Asymptomatic Severe Aortic Stenosis Involving Three-Cuspid Valves

Cited by 61 publications

References 25 publications

Two-Dimensional Strain for the Assessment of Left Ventricular Function in Low Flow–Low Gradient Aortic Stenosis, Relationship to Hemodynamics, and Outcome

Two-Dimensional Strain for the Assessment of Left Ventricular Function in Low Flow–Low Gradient Aortic Stenosis, Relationship to Hemodynamics, and Outcome

Association of Myocardial Deformation With Outcome in Asymptomatic Aortic Stenosis With Normal Ejection Fraction

Outcomes in Asymptomatic Severe Aortic Stenosis With Preserved Ejection Fraction Undergoing Rest and Treadmill Stress Echocardiography

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