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Longitudinal Strain in Mixed Aortic Valve Disease Phenotypes
Quick Takes
- Left ventricular global longitudinal strain (LV-GLS) in patients with mixed aortic valve disease (MAVD) with preserved LVEF depends on the relative severity of concomitant aortic stenosis and regurgitation, and worse LV-GLS is associated with higher mortality.
- Patients with MAVD have subclinical LV dysfunction despite preserved LVEF, and this subclinical dysfunction is related to poor prognosis.
- Additional prospective studies are needed to assess the utility of LV-GLS in defining the need for AVR in patients with MAVD given the lack of a specific guideline recommendation for the appropriate timing of AVR in patients with MAVD.
Study Questions:
What is the interplay between mixed aortic valve disease (MAVD) phenotypes (defined by concomitant severities of aortic stenosis and aortic regurgitation) and left ventricular global longitudinal strain (LV-GLS), and the prognostic utility of LV-GLS in MAVD?
Methods:
The investigators conducted an observational cohort study and evaluated 783 consecutive adult patients with left ventricular ejection fraction (LVEF) ≥50% and MAVD, which was defined as coexisting with at least moderate aortic stenosis and at least moderate aortic regurgitation. They measured the conventional echocardiographic variables and average LV-GLS from apical long, two- and four-chamber views. The primary endpoint was all-cause mortality. Survival was estimated using the Kaplan-Meier method, and differences between survival curves were tested with a log-rank test. To assess association between LV-GLS and outcomes after controlling for other echocardiographic and clinical variables, a two-step multivariable Cox proportional hazards analysis was performed.
Results:
Mean age of patients was 69 ± 15 years, and 58% were male. Mean LV-GLS was -14.7 ± 2.9%. In total, 458 patients (59%) underwent aortic valve replacement (AVR) at a median period of 50 days (25th-75th percentile range, 6-560 days). During a median follow-up period of 5.6 years (25th-75th percentile range, 1.8-9.4 years), 391 patients (50%) died. When stratified patients were put into tertiles according to LV-GLS values, patients with worse LV-GLS had worse outcomes (p < 0.001). LV-GLS was independently associated with mortality (hazard ratio, 1.09; 95% confidential interval, 1.04-1.14; p < 0.001), with the relationship between LV-GLS and mortality being linear.
Conclusions:
The authors concluded that LV-GLS is associated with all-cause mortality and may be useful for risk stratification in patients with MAVD.
Perspective:
This study reports that LV-GLS in patients with MAVD with preserved LVEF depends on the relative severity of concomitant aortic stenosis and regurgitation, and worse LV-GLS is associated independently with higher mortality. Furthermore, worse (preoperative) LV-GLS values remained independently associated with higher mortality even after AVR. Overall, these data suggest that patients with MAVD have subclinical LV dysfunction despite preserved LVEF, and this subclinical dysfunction is related to poor prognosis. Additional prospective studies to assess the utility of LV-GLS in defining the need for AVR in patients with MAVD are needed given the lack of a specific guideline recommendation for the appropriate timing of AVR in patients with MAVD.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Aortic Valve Insufficiency, Aortic Valve Stenosis, Cardiac Surgical Procedures, Diagnostic Imaging, Echocardiography, Heart Valve Diseases, Heart Valve Prosthesis, Phenotype, Risk Assessment, Secondary Prevention, Stroke Volume, Transcatheter Aortic Valve Replacement, Ventricular Dysfunction, Left
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