Abstract
AimsThe aim of present study was to examine the preoperative prevalence and distribution of impaired left ventricular global longitudinal strain (LVGLS) in elderly patients with symptomatic aortic stenosis (AS) undergoing transcutaneous aortic valve replacement (TAVR) and to determine the predictive value of LVGLS on survival.MethodsWe included 411 patients with symptomatic severe AS treated with TAVR during a 5-year period, where a baseline echocardiography including LVGLS assessment was available.ResultsMean age was 80.1 ± 7.1 years and aortic valve area (AVA) index 0.4 ± 0.1 cm2. 78 patients died during a median follow-up of 762 days. Mean left ventricular ejection fraction (LVEF) was 50 ± 13% and mean LVGLS was − 14.0%. LVEF was preserved in 60% of patients, while impaired LVGLS > − 18% was seen in 75% of the patients. Previous myocardial infarction, LVEF < 50%, LVGLS > − 14%, low gradient AS (< 4.0 m/s), tricuspid regurgitant gradient > 30 mmHg were identified as significant univariate predictors of all-cause mortality. On multivariate analysis LVGLS > − 14% (HR 1.79 [1.02–3.14], p = 0.04) was identified as the only independent variable associated with all-cause mortality. Reduced survival was observed with an impaired LVGLS > − 14% in the total population (p < 0.002) but also in patients with high AS gradient with preserved LVEF. LVGLS provided incremental prognostic value with respect to clinical characteristics, AVA and LVEF (χ2 19.9, p = 0.006).ConclusionsIn patients with symptomatic AS undergoing TAVR, impaired LVGLS was highly prevalent despite preserved LVEF. LVGLS > − 14% was an independent predictor of all-cause mortality, and survival was reduced if LVGLS > − 14%.
Highlights
Surgical aortic valve replacement (SAVR) is considered gold standard therapy in severe aortic stenosis (AS) alleviating symptoms, improving quality of life and prolonging survival [1]
The distribution of left ventricular ejection fraction (LVEF) and left ventricular global longitudinal strain (LVGLS) according to predefined intervals in the overall AS population are shown in Fig. 1a, b
The main findings of this study investigating elderly symptomatic patients with severe AS undergoing transcutaneous aortic valve replacement (TAVR) are: (1) LVEF was preserved in 60% of the patients despite advanced symptoms in contrast to LVGLS that was abnormal in 75% (> − 18%) and at least moderately decreased (> − 14%) in approximately half of the patients; (2) a highly significant correlation between LVGLS and all-cause mortality was identified; (3) LVGLS > − 14% was identified as an independent predictor of all-cause mortality and patients with a LVGLS > − 14% had reduced long-term survival as compared to patients with LVGLS ≤ − 14%; (4) patients with high gradient AS with preserved LVEF but LVGLS > − 14% had reduced survival as compared to patients with LVGLS ≤ − 14%
Summary
Surgical aortic valve replacement (SAVR) is considered gold standard therapy in severe aortic stenosis (AS) alleviating symptoms, improving quality of life and prolonging survival [1]. Povlsen et al BMC Cardiovasc Disord (2020) 20:506 replacement (TAVR) is often the preferred strategy for treatment of symptomatic severe AS in elderly patients with intermediate and high perioperative risk [2, 3]. The current guidelines recommend SAVR or TAVR for severe AS once symptoms occur or when left ventricular ejection fraction (LVEF) is < 50% [4, 5]. To determine whether patients are truly asymptomatic or even symptomatic can be challenging in the elderly and often frail AS patients considered for TAVR. Recommended in patients with unclear symptom status, is often not a diagnostic option as many patients are unable to perform this test [6]
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