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Original Investigation
September 2018

Association of Left Ventricular Global Longitudinal Strain With Asymptomatic Severe Aortic Stenosis: Natural Course and Prognostic Value

Author Affiliations
  • 1Heart Lung Center, Leiden University Medical Center, Leiden, the Netherlands
  • 2GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University of Liège Hospital, Centre Hospitalier Universitaire Sart Tilman, Liège, Belgium
  • 3Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
  • 4Department of Cardiology, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
  • 5Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
  • 6Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
  • 7Cardiovascular Research Foundation, New York, New York
  • 8New York–Presbyterian Hospital, Columbia University, Medical Center, New York
  • 9Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
  • 10Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Quebec, Canada
JAMA Cardiol. 2018;3(9):839-847. doi:10.1001/jamacardio.2018.2288
Key Points

Question  What is the natural course of left ventricular global longitudinal strain (LV GLS) and prevalence and prognostic value of impaired LV GLS in patients with asymptomatic severe aortic stenosis (AS) and preserved left ventricular ejection fraction?

Findings  In this registry-based study of 220 patients, asymptomatic patients with severe AS showed significantly impaired LV GLS compared with 220 controls with further deterioration over time. Patients with impaired LV GLS at baseline showed a higher risk for developing symptoms and requiring aortic intervention.

Meaning  Subclinical myocardial dysfunction that is characterized by impaired LV GLS is often present in patients with asymptomatic severe AS and is associated with symptom development and the need for intervention.

Abstract

Importance  The optimal timing to operate in patients with asymptomatic severe aortic stenosis (AS) remains controversial. Left ventricular global longitudinal strain (LV GLS) may help to identify patients who might benefit from undergoing earlier aortic valve replacement.

Objective  To investigate the prevalence of impaired LV GLS, the natural course of LV GLS, and its prognostic implications in patients with asymptomatic severe AS with preserved left ventricular ejection fraction (LVEF).

Design, Setting, and Participants  This registry-based study included the institutional registries of 3 large tertiary referral centers and 220 patients with asymptomatic severe AS and preserved LVEF (>50%) who were matched for age and sex with 220 controls without structural heart disease. The echocardiograms of patients and controls were performed between 1998 and 2017.

Exposures  Both clinical and echocardiographic data were assessed retrospectively. Severe AS was defined by an indexed aortic valve area less than 0.6 cm2/m2. Left ventricular global longitudinal strain was evaluated on transthoracic echocardiography using speckle tracking imaging.

Main Outcomes and Measures  The prevalence of impaired LV GLS, the natural course of LV GLS, and the association of impaired LV GLS with symptom onset and the need for aortic valve intervention.

Results  Two hundred twenty patients (mean [SD] age, 68 [13] years; 126 men [57%]) were included. Despite comparable LVEF, LV GLS was significantly impaired in patients with asymptomatic severe AS compared with age- and sex-matched controls without AS (mean [SD] LV GLS, −17.9% [2.5%] vs −19.6% [2.1%]; P < .001). After a median follow-up of 12 (interquartile range, 7-23) months, mean (SD) LV GLS significantly deteriorated (−18.0% [2.6%] to −16.3% [2.8%]; P < .001) while LVEF remained unchanged. Patients with impaired LV GLS at baseline (>−18.2%) showed a higher risk for developing symptoms (P = .02) and needing aortic valve intervention (P = .03) at follow-up compared with patients with more preserved LV GLS (≤−18.2%).

Conclusions and Relevance  Subclinical myocardial dysfunction that is characterized by impaired LV GLS is often present in patients with asymptomatic severe AS with preserved LVEF. Left ventricular global longitudinal strain further deteriorates over time and impaired LV GLS at baseline is associated with an increased risk for progression to the symptomatic stage and the need for aortic valve intervention.

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