Symptoms in Severe Aortic Stenosis are Associated with Decreased Compensatory Circumferential Myocardial Mechanics

Carasso, Shemy; Mutlak, Diab; Lessick, Jonathan; Reisner, Shimon A.; Rakowski, Harry; Agmon, Yoram

doi:10.1016/j.echo.2014.09.006

Cited by 21 publications

(18 citation statements)

References 28 publications

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“…It can be challenging to clinicians to decipher a genuine change in symptoms attributable to AS. Similar to previous studies (19,21), our work highlights the need for novel objective measures of early LV decline that could guide a clinician to offering timely intervention. This is the first study to use CMR strain analysis to attempt to differentiate patients with severe AS based on their symptomatic state.…”

Section: Discussionsupporting

confidence: 49%

“…The origin of exercise intolerance or symptoms in patients with severe AS is poorly understood (19) and there is considerable variation in the degree of stenosis associated with symptom onset. In our study, patients with no/mild and significant symptoms were comparable in age, LVEF, LV mass, mitral regurgitation, presence of pulmonary hypertension (PHT), history of coronary disease and aortic valve haemodynamics.…”

Section: Discussionmentioning

confidence: 99%

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Myocardial strain and symptom severity in severe aortic stenosis: insights from cardiovascular magnetic resonance

Musa¹,

Uddin²,

Swoboda³

et al. 2017

Quant. Imaging Med. Surg.

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Background: Symptomatic severe aortic stenosis (AS) is a class I indication for replacement in patients when left ventricular ejection fraction (LVEF) is preserved. However, symptom reporting is often equivocal and decision making can be challenging. We aimed to quantify myocardial deformation using cardiovascular magnetic resonance (CMR) in patients classified by symptom severity.Methods: Forty-two patients with severe AS referred to heart valve clinic were studied using tagged CMR imaging. All had preserved LVEF. Patients were grouped by symptoms as either "none/mild" (n=21, NYHA class I, II) or "significant" (n=21, NYHA class III, IV, angina, syncope) but were comparable for age (72.8±5.4 vs. 71.0±6.8 years old, P=0.345), surgical risk (EuroSCORE II: 1.90±1.7 vs. 1.31±0.4, P=0.302) and haemodynamics (peak aortic gradient: 55.1±20.8 vs. 50.4±15.6, P=0.450). Thirteen controls matched in age and LVEF were also studied. LV circumferential strain was calculated using inTag © software and longitudinal strain using feature tracking analysis.Results: Compared to healthy controls, patients with severe AS had significantly worse longitudinal and circumferential strain, regardless of symptom status. Patients with "significant" symptoms had significantly worse peak longitudinal systolic strain rates (−83.352±24.802%/s vs. −106.301±43.276%/s, P=0.048) than those with "no/mild" symptoms, with comparable peak longitudinal strain (PLS), peak circumferential strain and systolic and diastolic strain rates. Conclusions:Patients with severe AS who have no or only mild symptoms exhibit comparable reduction in circumferential and longitudinal fibre function to those with significant symptoms, in whom AVR is clearly indicated. Given these findings of equivalent subclinical dysfunction, reportedly borderline symptoms should be handled cautiously to avoid potentially adverse delays in intervention.

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Section: Discussionsupporting

confidence: 49%

Section: Discussionmentioning

confidence: 99%

Myocardial strain and symptom severity in severe aortic stenosis: insights from cardiovascular magnetic resonance

Musa¹,

Uddin²,

Swoboda³

et al. 2017

Quant. Imaging Med. Surg.

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“…ApRot is typically increased in patients with AS. 10,12,17 Our study population had a mean peak ApRot of 5.1 , which is consistent with previous studies that found ApRot to be lower in patients with normal LVEFs (Carasso et al, 18 3.2 6 2.0 ) and those who are symptomatic (Carasso et al, 14 2.9 6 1.7 ). Our study population all had normal LVEFs, and 63% were symptomatic.…”

Section: The Role Of Aprot In Systolic Function and Outcomessupporting

confidence: 92%

“…Therefore, we would caution against using our reported absolute ApRot values as a reference or cut point, even though they are consistent with ApRot values of similar patients in other studies. 14,18 With continued efforts by the American Society of Echocardiography and European Association of Cardiovascular Imaging task force and vendors to standardize ApRot measurement, and consensus among investigators on image acquisition and analysis, it is likely that this measurement variation will be reduced and reference ranges will be established in the future.…”

Section: Image Acquisition and Analysis Standardizationmentioning

confidence: 98%

“…Increased ApRot in patients with severe AS was associated with chest pain or electrocardiographic LV strain pattern in one study, 13 but another study reported decreased ApRot to be more associated with the presence of symptoms overall. 14 The association between ApRot and survival in severe AS is yet to be reported. ApRot is key to cardiac performance, and understanding the interplay between ApRot, symptoms, and survival is key to defining a comprehensive model of myocardial deformation and its impact on clinical outcomes.…”

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confidence: 99%

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Increased Apical Rotation in Severe Aortic Stenosis is Associated with Reduced Survival: A Speckle-Tracking Study

Holmes

Taub

García

et al. 2015

Journal of the American Society of Echocardiography

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Different responses of the myocardial contractility by layer following acute pressure unloading in severe aortic stenosis patients

Kim

Lee

Park

et al. 2015

Int J Cardiovasc Imaging

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The present study evaluated change in left ventricle (LV) biomechanics, layer-by-layer, following acute pressure unloading in patients with severe aortic stenosis (AS). In twenty-eight consecutive patients with severe AS who underwent transcatheter aortic valve replacement (TAVR), LV peak global longitudinal and circumferential strains of the endo-, midmyo- and epicardium were evaluated using multilayer speckle tracking echocardiography before, 1 week after, and 1 month after TAVR. Longitudinal and circumferential strains were significantly highest in the endocardium and lowest in the epicardium at baseline. At 1 month following TAVR, longitudinal strain significantly improved in all layers compared with the baseline [endocardium (%) -16.7 ± 3.8 vs. -18.6 ± 3.3, P = 0.01; mid-myocardium -14.4 ± 3.2 vs. -16.2 ± 3.5, P < 0.01; epicardium -12.4 ± 2.8 vs. -13.6 ± 2.6, P = 0.01], whereas LV ejection fraction and circumferential strain remained unchanged. Importantly, only those with LV hypertrophy demonstrated improved longitudinal strain [endocardium (%) -15.7 ± 3.0 vs. -18.7 ± 2.9, P < 0.01; mid-myocardium -13.6 ± 2.7 vs. -16.0 ± 2.5, P < 0.01; epicardium -11.8 ± 2.4 vs. -13.7 ± 2.3, P < 0.01]. The improvement in longitudinal strain was more prominent in the endocardium, which was evident even at an early time point (1 week) after TAVR. Longitudinal strain significantly improved in all three layers following acute pressure unloading, the most prominent of which was observed in the endocardium. Evaluation of multilayer strain may provide new insights into the LV mechanics in the future.

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Symptoms in Severe Aortic Stenosis are Associated with Decreased Compensatory Circumferential Myocardial Mechanics

Cited by 21 publications

References 28 publications

Myocardial strain and symptom severity in severe aortic stenosis: insights from cardiovascular magnetic resonance

Myocardial strain and symptom severity in severe aortic stenosis: insights from cardiovascular magnetic resonance

Increased Apical Rotation in Severe Aortic Stenosis is Associated with Reduced Survival: A Speckle-Tracking Study

Different responses of the myocardial contractility by layer following acute pressure unloading in severe aortic stenosis patients

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