Early Diastolic Strain Rate in Relation to Systolic and Diastolic Function and Prognosis in Aortic Stenosis
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JACC: CARDIOVASCULAR IMAGING VOL.9,NO.5,2016 ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 1936-878X/$36.00 PUBLISHED BY ELSEVIER http://dx.doi.org/10.1016/j.jcmg.2015.06.029 Early Diastolic Strain Rate in Relation to Systolic and Diastolic Function and Prognosis in Aortic Stenosis a b a a Jordi S. Dahl, MD, PHD, Sergio Barros-Gomes, MD, Lars Videbæk, MD, PHD, Mikael K. Poulsen, MD, PHD, a a a a Issa F. Issa, MD, Rasmus Carter-Storch, MD, Nicolaj Lyhne Christensen, MD, Anja Kumme, MD, DMSCI, b a Patricia A. Pellikka, MD, Jacob E. Møller, MD, PHD, DMSCI ABSTRACT OBJECTIVES This study examined the impact of early mitral inflow velocity-to-early diastolic strain rate (E/SRe) ratio on long-term outcome after aortic valve replacement (AVR) in aortic stenosis (AS). BACKGROUND In AS, increased filling pressures are associated with a poor prognosis and can be estimated using the early diastolic mitral inflow velocity-to-early diastolic velocity of the mitral annulus (E/e0) ratio. Recent studies suggest that the E/SRe ratio surpasses the E/e0 ratio in estimating outcome. METHODS Pre-operative evaluation was performed in 121 patients with severe AS (aortic valve area <1cm2) and left ventricular ejection fraction (LVEF) of >40% who were scheduled for AVR. Patients were divided according to E/SRe median and followed for 5 years. The primary endpoint was overall mortality. RESULTS LVEF was lower (53 Æ 7% vs. 56 Æ 7%, respectively; p ¼ 0.03) and a restrictive filling pattern more common (28% vs. 8%, respectively, p ¼ 0.005) in patients with increased E/SRe ratio. Five-year overall mortality was increased in patients with high E/SRe (40% vs. 15%, respectively; p ¼ 0.007). In univariate Cox regression analysis, E/SRe, age, European System for Cardiac Operative Risk Evaluation (EuroSCORE), LV mass index, left atrial volume index, LVEF, global longitudinal strain, E/e0 ratio, and N-terminal pro–B-type natriuretic peptide level were univariate predictors of overall mortality, although when we adjusted for the predefined variables age, history of diabetes mellitus and LVEF, only E/SRe and left atrial volume index remained associated with overall mortality. Even when we included left atrial volume index in the multivariate model, E/SRe was significantly associated with overall mortality (hazard ratio [HR]: 2.2; 95% confidence interval [CI]: 1.1 to 4.4; p < 0.05); additionally, in a model with forward selection, E/SRe was the sole predictor (HR: 2.9; 95% CI: 1.6 to 5.5; p ¼ 0.001. The overall log likelihood chi-square analysis of the predictive power of the multivariate model containing E/SRe was statistically superior to models based on the E/e0 ratio. CONCLUSIONS Pre-operative E/SRe ratio was significantly associated with long-term post-operative survival and was superior to the E/e0 ratio in patients with severe AS undergoing AVR. (Effect of Angiotensin II Receptor Blockers (ARB) on Left Ventricular Reverse Remodelling After Aortic Valve Replacement in Severe Valvular Aortic Stenosis; NCT00294775) (J Am Coll Cardiol Img 2016;9:519–28) © 2016 by the American College of Cardiology Foundation. ortic stenosis (AS) is characterized by left dysfunction, increased filling pressure, and wors- A ventricular (LV) pressure overload leading to ening prognosis (1–3). A cornerstone in assessing dia- LV hypertrophy and fibrosis. The conse- stolic function and estimating filling pressure quence is increased chamber stiffness and delayed noninvasively is assessment of the early diastolic active LV relaxation, which will cause LV diastolic mitral inflow velocity-to-early diastolic velocity of From the aDepartment of Cardiology, Odense University Hospital, Odense, Denmark; and the bDivision of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota. This study was funded by the Danish Heart Foundation, the Family Hede Nielsen’s Fund, the Augustinus Fund, and the Brødrene Hartmanns Fund. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received April 21, 2015; revised manuscript received June 16, 2015, accepted June 18, 2015. Downloaded From: http://imaging.onlinejacc.org/ by Marcia Barbosa on 06/22/2016 520 Dahl et al. JACC: CARDIOVASCULAR IMAGING, VOL. 9, NO. 5, 2016 Strain Imaging in Aortic Stenosis MAY 2016:519– 28 ABBREVIATIONS the mitral annulus (E/e0)ratio(3,4). Recent was superior to E/e0 in predicting cardiovascular AND ACRONYMS studies, however, have raised some impor- events among patients with myocardial infarction (9). tant concerns about the E/e0 ratio (4–6), Whether this also is the case among patients with AS AS = aortic stenosis some of which are related to angle depen- is not known. We thus hypothesized that E/SRe AUC = area under the curve dency and the effect of passive tethering of e0. wouldbeassociatedwithadverseoutcomeafter AVR = aortic valve Measurement of the early mitral inflow aortic valve replacement (AVR) among patients with replacement velocity-to-early diastolic strain rate (E/SRe) severe symptomatic AS and that the E/SRe ratio GLS = global longitudinal 0 strain ratio has recently been proposed as a novel would provide incremental information to E/e . marker of elevated LV filling pressure (7,8). LA = left atrial SEE PAGE 529 The potential advantage of this marker is that LV = left ventricular the regional early velocity of diastolic defor- METHODS LVEF = left ventricular ejection fl fraction mation (strain rate) more accurately re ects diastolic performance of all myocardial seg- The present investigation was a post-hoc analysis of NT-proBNP = N-terminal pro- B-type natriuretic peptide ments. Moreover, based on 2-dimensional a prospective, single-center, randomized study SRe = early diastolic strain rate (2D) speckle tracking echocardiography, dia- conducted to evaluate the effect of candesartan stolic deformation is less depending on in addition to conventional treatment on reverse insonation angle. In a recent paper, the E/SRe ratio remodelling in consecutive patients undergoing AVR FIGURE 1 Example of Measurement of E/SRe Measurements are shown of early mitral inflow velocity (E) using pulse-wave Doppler and early diastolic strain rate (SRe) from 2D speckle tracking. AVC ¼ aortic valve closure. Downloaded From: http://imaging.onlinejacc.org/ by Marcia Barbosa on 06/22/2016 JACC: CARDIOVASCULAR IMAGING, VOL. 9, NO. 5, 2016 Dahl et al. 521 MAY 2016:519– 28 Strain Imaging in Aortic Stenosis for symptomatic AS. The study was registered with the TABLE 1 Patient Characteristics National Board of Health and Danish Data Protection Agency,approvedbythelocalethicscommittee,and E/SRe <0.93 E/SRe $0.93 (n ¼ 60) (n ¼ 61) p Value registered with (NCT00294775). All patients gave Age, yrs 71 Æ 10 74 Æ 8 0.11 written informed consent. The study design and Number of males 40 (66) 37 (61) 0.49 effect of candesartan on regression of LV hyper- Atrial fibrillation occurrence 9 (15) 10 (16) 0.83 trophy was published previously (10).Briefly, we Hypertension occurrence 27 (45) 26 (43) 0.79 enrolled patients >18 years if age with symptomatic Diabetes mellitus occurrence 6 (10) 12 (18) 0.14 severe AS (Doppler-derived aortic valve area <1cm2) Ischemic heart disease occurrence 17 (28) 20 (33) 0.60 scheduled for AVR at Odense University Hospital, Number of subjects with NYHA functional 10/35/15 13/29/19 0.53 class shown (I/II/III) Denmark, between February 2006 and April 2008. Pa- 6-min walk test, m 360 Æ 116 332 Æ 127 0.26 tients with left ventricular ejection fraction (LVEF) EuroSCORE 5.4 Æ 1.9 6.0 Æ 2.0 0.08 <40%, s-creatinine concentration >220 mmol/l, previ- Logistic EuroSCORE 4.7 Æ 3.1 6.1 Æ 4.5 0.04 ous aortic valve surgery, planned additional valve BSA, m2 1.8 Æ 0.3 1.9 Æ 0.5 0.39 repair/replacement, infective endocarditis, predomi- Systolic blood pressure, mm Hg 145 Æ 21 147 Æ 20 0.66 nant aortic valve regurgitation, or ongoing treatment Number of types of treatment shown Diuresis 16 (27) 26 (43) 0.07 with an angiotensin-convertingenzymeinhibitororan Beta-blocker therapy 12 (20) 15 (25) 0.54 angiotensin receptor blocker were excluded. Calcium channel blocker therapy 11 (18) 14 (23) 0.53 fi Ischemic heart disease was de ned as a history Candesartan therapy 30 (50) 31 (51) 0.93 of myocardial infarction, previous revascularization Number of surgery types with percutaneous coronary intervention, or coronary Concomitant CABG 16 (27) 20 (33) 0.46 artery bypass grafting or, if pre-operative coronary Mechanical prosthesis 10 (17) 9 (15) 0.74 angiography demonstrated, significant stenosis Prosthesis size, mm 23.1 Æ 4.7 22.7 Æ 4.7 0.68 m Æ Æ requiring coronary artery bypass grafting in addition Creatinine concentration, mol/l 102 24 99 19 0.35 Biomarkers concentration to AVR. NT-proBNP, pmol/l 315 (148–664) 805 (259–5,868) 0.0002 Fibulin-1, mg/ml 76 (61–100) 90 (72–108) 0.05 ECHOCARDIOGRAPHY. All echocardiograms were performed by a single experienced operator using a Values are mean Æ SD, n (%), or median (interquartile range). Vivid 5 ultrasonography system (GE Medical System, BSA ¼ body surface area; CABG ¼ coronary artery bypass graft; NYHA ¼ New York Heart Association. Horten, Norway) on the day prior to surgery. Images were obtained with a minimum frame rate of 70 frames/s. For all Doppler recordings, a horizontal Relative wall thickness was calculated using the for- sweep of 100 mm/s was used; for patients in sinus mula: [2 Â posterior wall thickness / LV internal rhythm, the average of 5 consecutive beats were diameter in diastole] (13).LVEFwasestimatedusing measured; for patients with atrial fibrillation, 10 beats Simpson’s biplane method.