Preoperative Global Longitudinal Strain Research Articles

Optimal Global Longitudinal Strain Thresholds for Pediatric Heart Surgery: Insights from a University Hospital.

Congenital heart diseases impact millions annually, with pediatric care lacking suitable risk assessment tools. This research seeks to illuminate the association between the global longitudinal strain (GLS) and the subsequent impact on postoperative outcomes, contributing to a deeper understanding of its predictive value in the pediatric population affected by congenital heart diseases. An observational, analytic, longitudinal, and prospective study was conducted from May 2022 to May 2023, including all patients under 18 undergoing heart surgery with cardiopulmonary bypass (CBP). Patients not classifiable within the Risk Adjustment for Congenital Heart Surgery were excluded. Using transesophageal echocardiography, GLS was measured pre- and post-CPB. Receiver operating characteristic curve analysis determined GLS cut-off points for 30-day mortality risk, using Youden's method for optimal sensitivity and specificity. Bivariate and multivariate analysis identified the relationships between clinical variables. Eighty-nine patients undergoing congenital heart surgery were included. Fifteen deaths occurred. The area under the curve (AUC) for each GLS classification (pre, post, index) demonstrated effective discriminatory capacity (> 0.70) in predicting 30-day mortality. Pre-CBP GLS showed the strongest predictive power (AUC 0.833, IQR: 0.731 - 0.936) with a cut-off point of 12. Values lower than the cut-off point of pre-CPB GLS correlated with increased vasoactive-inotropic Scores and longer mechanical ventilation. GLS measurement is a reproducible method for assessing ventricular function in pediatric heart surgery, showing potential as a prognostic tool. This study marks the initial effort to establish cut-off points for preoperative GLS, postoperative GLS, and the strain index.

Preprocedural global myocardial work index independently predicts NT-proBNP in patients undergoing transcatheter aortic valve replacement: a prospective study

Abstract Global myocardial work index is a novel echocardiographic parameter of the left ventricular (LV) function, which may overcome the load-sensitvity of the traditional functional measures by measuring LV deformation in the context of simultaneous pressures. This approach may gain particular importance in pressure overload states, such as patients with severe aortic stenosis. However, the longitudinal changes of this recently introduced measure are scarcely investigated in this population, and data are also lacking about its association with functional improvement following transcatheter aortic valve replacement (TAVR). Accordingly, our aim was to investigate the clinical determinants of preoperative and also postoperative GMWI in patients undergoing TAVR. Eighty-four patients (54%% male, age: 79±6 years) were enrolled. Prior to the procedure, subjects underwent echocardiographic investigation and the detailed medical history was also recorded. Serum NT-proBNP levels were also measured. We calculated LV ejection fraction and LV end-diastolic volume (EDV), and speckle-tracking analysis was performed to measure global longitudinal strain (GLS). As an accepted method of its estimation, LV pressure curve was generated by adding the mean aortic valve gradient to the systolic blood pressure. Using these measures, global myocardial work index (GMWI) was quantified by commercially available software. 12 months after the procedure, the patients underwent a follow-up echocardiographic examination, and at that time point we determined the same measures. At follow-up, GLS has significantly increased (-13.5±4.5 vs. -15.2±3.6%; p<0.001), while GMWI was significantly lower at the follow-up assessment (1913±786 vs. 1666±594 mmHg%, p<0.01). Compared to the preoperative values, LVEDV also showed a significant decrease at follow-up (115±46 vs. 105±41 mL, p<0.01). Using multivariable analysis, atrial fibrillation (β=0.36; p<0.001) ischemic heart disease (β=0.20; p<0.05) and also GMWI (β=-0.22; p<0.05) were found to be independent predictors of the postoperative NT-proBNP (R2=0.36; overall p<0.001). Importantly, by replacing GMWI to GLS, the latter did not enter the model as a predictor (β=0.17, p=0.11). TAVR significantly alters LV functional and morphological measures. Regarding the functional outcome of the patients, different clinical factors influence NT-proBNP after the procedure. Possibly due to its significant load dependency, preoperative GLS failed to predict NT-proBNP at follow-up, while GMWI was an independent precictor of NT-proBNP at follow up along with atrial fibrillation and ischemic heart disease. GMWI may serve as a useful imaging marker of preprocedural patient assessment before TAVR.

Myocardial Function after Coronary Artery Bypass Grafting in Patients with Preoperative Preserved Left Ventricular Ejection Fraction-The Role of the Left Ventricular Longitudinal Strain.

Background and Objectives: The role of coronary artery bypass grafting (CABG) on postoperative left ventricular (LV) function in patients with preoperatively preserved left ventricular ejection fraction (LVEF) is still being discussed and only a few studies address this question. This study aimed to assess LV function after CABG in patients with preoperatively preserved LVEF using left ventricular longitudinal strain assessed by 2D speckle tracking imaging (STI). Materials and Methods: Fifty-nine consecutive adult patients with coronary artery disease (CAD) referred for a first-time elective CABG surgery were enrolled in the final analysis of this prospective single-center clinical study. Transthoracic echocardiography (TTE), with conventional measures and STI measures, was performed within 1 week before CABG as well as 4 months after surgery. Patients were divided into groups based on their preoperative global longitudinal strain (GLS) value. Differences in systolic and diastolic parameters between groups were analyzed. Results: Preoperative GLS was reduced (GLS < -17%) in 39% of the patients. Parameters of systolic LV function were significantly reduced in this group of patients compared to the patient group with GLS% ≥ -17%. In both groups, 4 months after CABG there was a decline in LVEF but statistically significant only in the group with GLS% ≥ -17% (p = 0.035). In patients with reduced GLS, there was a statistically significant postoperative improvement (p = 0.004). In patients with preoperative normal GLS, there was not a significant change in any strain parameters after CABG. There was an improvement in diastolic function parameters measured by Tissue Doppler Imaging (TDI) in both groups. Conclusions: There is improvement in LV systolic and diastolic function after CABG in patients with preserved preoperative LVEF measured by STI and TDI. GLS might be more sensitive and effective than LVEF for monitoring improvements in myocardial function after CABG surgery in patients with preserved LVEF.

Value of Left Ventricular Strain Imaging Echocardiography in Predicting Outcomes after Severe Mitral Valve Regurgitation Surgery

Purpose: A new indicator of measuring ventricular systolic function is myocardial strain. However, it is unclear if longitudinal strain following mitral valve surgery has any predictive utility in clinical settings. The best time of operation is usually detected through the left ventricular internal dimensions as well as the function.. So this study aimed to evaluate the utility of myocardial strain by echocardiogram with other parameters in forecasting postoperative outcomes after primary MR surgery.&#x0D; Methodology: This prospective study enrolled 514 patients (279 males and 235 females; mean age (SD) of male participants was 57.3 (12.9). Included patients had severe primary mitral valve regurgitation and were candidates for valve surgery from April 2018 to April 2022. Patients with combined valvular disease as severe mitral stenosis, redo mitral valve replacement, and previous CABG and ischemic heart disease were excluded. Global longitudinal strain (GLS) was performed. Hospital re-admission for heart failure symptoms, reoperation and mortality were followed up as Cardiac incidents.&#x0D; Findings: In median follow-up of about four years, Age, previous ischemia, concomitant CABG, left atrial size, LVEF%, atrial fibrillation and Global longitudinal strain were all predictive of heart incidents. Age, left atrial dimension, and GLS were independent predictors to heart incidents on multivariate analysis (HR: 1.386, 95% CI: 1.083-1.776; P &lt;0.004, HR: 1.003, 95% CI: 0.976-1.031; p value 0.018, HR: 1.192, 95% CI: 1.101-1.291; P &lt;0.001 respectively). All-cause mortality was linked to impaired GLS (HR: 0.003, 95% CI: 0.973-1.102; P =0.039).&#x0D; Recommendation: GLS has a substantial link to clinical outcomes and is a stronger forecaster to cardiac issues than standard measurements. Measuring pre-operative GLS among those with severe primary MR is essential for anticipating post-operative results and determining the ideal time to plan operation.

Preoperative Left Ventricular Global Longitudinal Strain Identifies Aortic Stenosis Patients with Improved Postoperative Recovery of Left Ventricular Geometry: A Prospective Cohort Study.

IntroductionThe left ventricular ejection fraction (LVEF) is commonly used as a marker of aortic stenosis (AS) disease severity and to indicate surgical intervention. However, an LVEF <50% identifies mainly advanced disease. Hence, earlier detection of subclinical LV systolic dysfunction may improve clinical decision-making. The global longitudinal strain (GLS) can identify subclinical systolic dysfunction at earlier stages of AS progression even in the presence of preserved LVEF. To this end, we evaluated the preoperative prognostic significance of the LVGLS to identify patients who will undergo a more extensive postoperative LV reverse remodeling as a surrogate marker for clinical recovery.MethodsWe performed a prospective observational study based on detailed pre- and postoperative 2D transthoracic echocardiographic examinations, including strain analysis with speckle tracking. We screened 60 consecutive patients with severe AS and a preoperative LVEF ≥50% indicated for surgery; 39 patients met the study entry criteria and consented to their participation.ResultsThe median age was 67 (range 30-79) years; 56.4% were female. At baseline, the GLS was 61.64±7.22%. Surgery led to an improvement in the GLS; the mean difference was 3.23% [95% CI=1.96 to 4.49%] during a median follow up time of 5 (interquartile range 4-6) months. The preoperative GLS correlated with the postoperative LV mass index (LVMI) r=0.526, P=0.001 and the intraventricular septal thickness in diastole (IVSd) r=0.462, P=0.003. Furthermore, patients with a normal GLS (≤-18.9%) at baseline experienced a better recovery of their LV morphology and systolic function during the postoperative course compared to those with an abnormal GLS (>-18.9%). The effect size, hedges g, was at least >0.75 for the LVMI, IVSd, intraventricular septal thickness in systole (IVSs), left ventricular posterior wall thickness in diastole (LVPWd) and LVEF, suggesting a clinically significant difference between subgroups at follow-up.ConclusionA normal preoperative left ventricular global longitudinal strain is associated with an improved left ventricular reverse remodeling and systolic function following surgery to resolve aortic stenosis.

Prognostic utility of global longitudinal strain (GLS) in patients with severe primary mitral regurgitation undergoing mitral valve surgery: a systematic review and meta-analysis

Abstract Background Mitral valve (MV) surgery is recommended for the treatment of chronic severe mitral regurgitation (MR). However, the optimal timing of surgery in patients with asymptomatic severe primary MR remains elusive. Global longitudinal strain (GLS) may provide additional prognostic value in predicting postoperative outcomes in patients with chronic severe primary mitral regurgitation (MR) undergoing MV surgery. Purpose We aimed to determine the prognostic value of GLS in predicting postoperative mortality and LV dysfunction among patients with chronic severe primary MR. Methods Systematic search of Pubmed, Cochrane library, Clinicaltrials.gov, and Herdin.ph from inception to July 2019, using the terms “mitral insufficiency”, “mitral regurgitation”, “mitral valve surgery”, and “global longitudinal strain” was done without language restriction. We included and extracted data from cohort studies of patients with chronic severe primary MR who underwent MV surgery and which GLS, mortality and ejection fraction. We used the Newcastle Ottawa Scale to assess the quality of included studies. Review Manager 5.3 was used to perform analysis. Forest plots with summary hazard ratios (HR) and odds ratios (OR) with 95% confidence intervals (CI), I2 test for heterogeneity, and funnel plots were reported. Results Our search yielded 12 cohort studies with 2,843 patients; 7 prospective and 5 retrospective studies were included in the qualitative synthesis with 11 good quality studies. Cut-off GLS values ranged from −21.7% to −18.1%. In terms of postoperative all-cause mortality, the summary HR for worse versus better preoperative GLS is 1.22 (95% CI 1.04–1.44, p value &amp;lt;0.ehab724.16031, I2 95%). In terms of postoperative LV dysfunction, the summary OR is 1.74 (95% CI 1.14–2.66, p value 0.01, I2 94%) with significant heterogeneity. Conclusion Left ventricular GLS has prognostic value in terms of predicting postoperative mortality and LV dysfunction. However, significant heterogeneity exists between studies. Larger studies with well-defined inclusion criteria need to be performed and standardized GLS cut-offs need to be determined. Funding Acknowledgement Type of funding sources: None. GLS in Predicting All-Cause MortalityGLS in Predicting Post-op Dysfunction

One-year impact of bariatric surgery on left ventricular mechanics: results from the prospective FatWest study.

AimsPatients with severe obesity are predisposed to left ventricular (LV) hypertrophy, increased myocardial oxygen demand, and impaired myocardial mechanics. Bariatric surgery leads to rapid weight loss and improves cardiovascular risk profile. The present prospective study assesses whether LV wall mechanics improve 1 year after bariatric surgery.Methods and resultsNinety-four severely obese patients [43 ± 10 years, 71% women, body mass index (BMI) 41.8 ± 4.9 kg/m2, 57% with hypertension] underwent echocardiography before, 6 months and 1 year after gastric bypass surgery in the FatWest (Bariatric Surgery on the West Coast of Norway) study. We assessed LV mechanics by midwall shortening (MWS) and global longitudinal strain (GLS), LV power/mass as 0.222 × cardiac output × mean blood pressure (BP)/LV mass, and myocardial oxygen demand as the LV mass-wall stress-heart rate product. Surgery induced a significant reduction in BMI, heart rate, and BP (P < 0.001). Prevalence of LV hypertrophy fell from 35% to 19% 1 year after surgery (P < 0.001). The absolute value of GLS improved by—4.6% (i.e. 29% increase in GLS) while LV ejection fraction, MWS, and LV power/mass remained unchanged. In multivariate regression analyses, 1 year improvement in GLS was predicted by lower preoperative GLS, larger mean BP, and BMI reduction (all P < 0.05). Low 1-year MWS was associated with female sex, preoperative hypertension, and higher 1-year LV relative wall thickness and myocardial oxygen demand (all P < 0.001).ConclusionIn severely obese patients, LV longitudinal function is largely recovered one year after bariatric surgery due to reduced afterload. LV midwall mechanics does not improve, particularly in women and patients with persistent LV geometric abnormalities.ClinicalTrials.gov identifierNCT01533142, 15 February 2012.

Global longitudinal strain to determine optimal timing for surgery in primary mitral regurgitation: A systematic review.

Primary mitral regurgitation (PMR) results in adverse remodeling changes and left ventricular (LV) dysfunction. Assessing LV function has prognostic value in predicting morbidity and mortality. Indications for surgery include parameters such as LV ejection fraction (LVEF) and systolic dimensions. Current guidelines are limited in identifying patients at optimal time for surgery. Impaired postoperative LVEF indicates poor prognostic outcomes and subsequent heart failure. Global longitudinal strain (GLS) via speckle tracking echocardiography (STE) presents as a promising parameter to detect subclinical dysfunction in asymptomatic patients. Following PRISMA guidelines, a literature search was conducted with Cochrane Library, PudMed, SCOPUS, and Web of Science. Key MeSH terms included "mitral regurgitation," "mitral valve insufficiency," "global longitudinal strain," "deformation," "LV-GLS," and "GLS." Inclusion criteria included (1) patients with severe PMR, (2) mixed population of symptomatic and asymptomatic patients, (3) standardized methods in assessing LV systolic function using 2D-STE, (4) valve repair or replacement surgery, and (5) patient outcomes measured after surgery. Search returned 234 papers, 12 of which met the inclusion criteria and were subsequently reviewed. Baseline GLS is an independent predictor of postoperative outcomes, ranging from -17.9 to -21.7% GLS. A significant negative correlation was observed between preoperative GLS and postoperative LVEF. Impaired baseline GLS was associated with higher mortality rates. Better long-term survival rates were seen in patients who underwent early surgery. GLS shows sensitivity in predicting long-term postoperative outcomes. Further analysis is required to determine preoperative GLS threshold to identify asymptomatic patients at the optimal time for mitral valve surgery.

Global Longitudinal Strain Predicts Survival and Left Ventricular Function After Mitral Valve Surgery: A Meta-analysis

The timing for surgical treatment in patients with primary organic severe mitral valve regurgitation and preserved left ventricular ejection fraction (LVEF) systolic is a challenge since it depends upon LV end systolic dimension and LVEF which may be late markers of LV dysfunction. Echocardiography is the most important tool in the diagnosis of mechanisms, etiology, severity, and hemodynamic consequences of mitral regurgitation. The global longitudinal strain (GLS), a new and sensitive method for the detection of LV dysfunction, might be a useful method for the evaluation of preclinical systolic dysfunction. Nevertheless, its role for predicting postoperative outcomes is not well established. A meta-analysis was performed to address the role of GLS in patients with severe mitral regurgitation and preserved LVEF who underwent mitral surgery. We included studies that compared outcomes according to preoperative GLS in regard to survival and postoperative LV function. We included 2358 patients enrolled in 8 studies. Patients with reduced GLS% had worse long term survival after mitral valve surgery (hazard ratio = 1.13, 95% confidence interval [CI]: 1.02-1.26). Patients with preoperatively reduced GLS% had lower LVEF after surgery (mean difference [MD] = -5.06%, 95% CI: -8.97-1.16%) and additionally, patients who presented postoperative LVEF dysfunction had worse preoperative GLS (MD = 4.33, 95% CI: 3.89-4.76). In patients with primary mitral regurgitation, preoperative GLS is a predictor for long term survival and postoperative LVEF. It is a useful parameter to be included when considering early surgery in patients with severe mitral regurgitation and normal LVEF.

Identification of Subclinical Myocardial Dysfunction and Association with Survival after Transcatheter Mitral Valve Repair

Transcatheter mitral valve repair (TMVr) using edge-to-edge mitral valve clip is effective for patients with mitral regurgitation (MR) and high or prohibitive surgical risk. Global longitudinal strain (GLS) allows evaluation of subclinical myocardial dysfunction, but its incremental clinical utility into risk stratification, beyond traditional clinical parameters, is unknown in patients treated with TMVr. We sought to evaluate the association of baseline GLS with 1-year all-cause mortality in patients treated with TMVr using edge-to-edge mitral valve clip. We analyzed 155 patients who underwent transcatheter edge-to-edge mitral valve clip implantation (mean age, 83±7years; 48% were women; mean left ventricular ejection fraction, 56%±10%, Society of Thoracic Surgeons Predicted Risk of Mortality score for repair, 6.62%±5.22%). Baseline left ventricular GLS was obtained by two-dimensional speckle-tracking echocardiography, averaging 18 segments from three apical views. Receiver operating characteristic analyses were used to assess the GLS cut point associated with all-cause mortality. Multivariable models with Cox regression tested its relationship after adjustment for baseline comorbidities. During a median follow-up of 316days, all-cause deaths occurred in 30 patients at a median of 156days after TMVr. The area under the curve of preoperative GLS associated with the outcome was 0.60, with a cutoff point of -14.5%. Baseline GLS>-14.5% was associated with 1-year mortality (hazard ratio=2.50; 95% CI, 1.20-5.21; P=.02) before and after adjustment for baseline characteristics. After accounting for baseline characteristics, patients with GLS>-14.5% had worse 1-year mortality than those with GLS≤-14.5% (χ2P<.001). In nested Cox proportional hazards models, the addition of baseline GLS to Society of Thoracic Surgeons Predicted Risk of Mortality score, left ventricular ejection fraction, and the etiology of MR significantly increased the model χ2 value (χ2=12.32). Baseline GLS is independently associated with 1-year all-cause mortality in patients who undergo TMVr, and its assessment improves risk stratification in these patients.

479Preoperative global longitudinal strain is the best predictor of mortality following transcatheter aortic valve replacement

Abstract Background Prognosis after transcatheter aortic valve replacement (TAVR) is variable. This might depend on preoperative evaluation of myocardial performance by other measurements than ejection fraction (EF). Purpose The aim of this study was to investigate the predictive value of preoperative global longitudinal strain (GLS) and the guidelines specified subtypes of aortic stenosis (AS) on mortality following TAVR. Methods We included 511 patients with severe AS who underwent TAVR in the period July 2012–June 2017. Patients were divided into guidelines-specified subgroups based on EF (EF: ≥50 (NEF) or &lt;50% (LEF)), peak gradient (PG: ≥4 (HG) or &lt;4 m/s (LG)) and flow status (stroke volume index (SVI): ≥35 (NF) or &lt;35 ml/min/kg (LF)): (1) HG-NEF (n=228), (2) HG-LEF (n=91), (3) LG-LF-NEF (n=71) and (4) LG-LF-LEF (n=121). We also investigated the effect of replacing EF by GLS in the guideline specified subgroups (GLS ≤−14 (HGLS) and GLS &gt;−14% (LGLS)). Results Mean follow up time was 1033 days. Mean age was 80.2±7.1 years. Median overall survival was 5.3±0.3 years. Comorbidity burden was higher in patients with LF – and LEF status in terms of a higher median plasma creatinine (103 [85; 135], p&lt;0.001) and EurologII score (6.1 [3.4; 9.6], p&lt;0.001). LG-LF-LEF AS was associated with a significantly worse outcome compared with all other groups (p&lt;0.005, Fig. 1A). High gradient status, irrespective of EF (p=0.88), was associated with the best prognosis with a median survival of 5.0±0.5 and 5.5±0.1 years for NEF and LEF, respectively. Overall and in patients with HG-NEF, impaired GLS (&gt;−14%) was associated with poor outcome (Fig. 1B–D). There was a trend towards a poorer prognosis with GLS &gt;−14% in LG-LF-NEF AS (p=0.10). In an univariate analysis impaired GLS &gt;−14% (HR 2.04, p&lt;0.005), LG-LF-LEF status (HR 1.82, p=0.001), PG &lt;4m/s (HR 1.74, p=0.001) and tricuspid regurgitation gradient &gt;30 mmHg (HR 1.63, p&lt;0.001) were significant predictors of mortality in contrast to EF, SVI, age, gender and plasma creatinine. GLS &gt;−14% emerged as the only significant outcome predictor in a multivariate analysis (HR 1.93, p&lt;0.05). Figure 1 Conclusion Impaired global longitudinal strain &gt;−14% was the best individual echocardiographic predictor of overall survival in symptomatic severe AS and could identify a subgroup of patients with HG-NEF AS with a worse prognosis.

Global longitudinal strain in prosthesis-patient mismatch: relation to left ventricular mass regression and outcomes.

Aortic prosthesis-patient mismatch (PPM) increases left ventricular (LV) afterload and prevents LV mass regression (LVMR) after surgery. This study was designed to investigate the association between the baseline global longitudinal strain (GLS) and the postoperative LVMR, and its relation to adverse outcomes. A total of 316 patients with aortic stenosis undergoing isolated mechanical prosthesis implantation were screened, and data from 91 patients with aortic PPM and 165 non-PPM patients were retrospectively collected. All 256 patients underwent measurement of GLS by two-dimensional speckle-tracking echocardiography preoperatively, and were followed up for postoperative changes of LV mass index (LVMi) and other clinical outcomes. During the follow-up, LVMi in PPM patients decreased significantly from 139.6 ± 20.8 to 119.6 ± 26.5 g/m (P < 0.001). These patients were divided into two groups according to the median value of the reduction rate of LVMi at final follow-up, and preoperative GLS markedly decreased in PPM patients with insignificant reduction in LVMi. Multivariate analysis identified preoperative GLS (odds ratio 3.45, 95% confidence interval 1.27-11.05, P = 0.002) and preoperative LVMi (odds ratio 2.87, 95% confidence interval 1.21-8.13, P = 0.012) as independently associated with an insignificant LVMR. Moreover, PPM patients with limited reduction in LVMi were at an increased risk of cardiac death and major adverse valve-related events. In patients with aortic PPM early after surgery, reduced preoperative GLS could be a novel sensitive risk factor for a limited regression of LV hypertrophy, and this is associated with an increased risk of adverse events in PPM patients.

Use of Pre-operative Global Longitudinal Strain to Predict Post-operative Left Ventricular Dysfunction in Mitral Regurgitation Surgery

Use of Pre-operative Global Longitudinal Strain to Predict Post-operative Left Ventricular Dysfunction in Mitral Regurgitation Surgery

300.11 Association of Baseline Global Longitudinal Strain with All-Cause Mortality in Patients Treated with Transcatheter Aortic Valve Replacement

Global longitudinal strain (GLS) detects subclinical myocardial dysfunction beyond left ventricular ejection fraction (LVEF) and is associated with poor outcomes in patients with aortic stenosis (AS). It remains unclear, however, if preoperative GLS is associated with the prognosis in patients with

Myocardial Strain in Prediction of Outcomes After Surgery for Severe Mitral Regurgitation

ObjectivesWe investigated whether global longitudinal strain (GLS) is a better predictor of clinical events after surgery for mitral regurgitation (MR) than conventional parameters. BackgroundThe optimal timing for surgery is guided by left ventricular (LV) dimension or left ventricular ejection fraction (LVEF), even though normal LVEF can mask depressed LV systolic function in severe mitral MR. MethodsFrom 2006 to 2016, 506 patients (age 58.5 ± 13.7 years, 54.3% male) with severe primary MR who underwent mitral valve surgery were included. We measured GLS and global circumferential strain. Cardiac events included admission for worsening heart failure (HF), reoperation for failure of MV surgery, and cardiac death. ResultsDuring a median follow-up period of 3.5 years, 56 (11.1%) patients died, 41 (8.1%) were hospitalized for HF, and 10 (2.0%) underwent reoperation. In univariate analysis, LVEF, atrial fibrillation, left atrial dimension, age, previous ischemia, concomitant coronary artery bypass graft, and both GLS and global circumferential strain were predictive of cardiac events. On multivariate Cox models, age (hazard ratio [HR]: 1.429, 95% confidence interval [CI]: 1.116 to 1.831; p = 0.005), left atrial dimension (HR: 1.034, 95% CI: 1.006 to 1.063; p = 0.019) and GLS (HR: 1.229, 95% CI: 1.135 to 1.331; p < 0.001) were independent predictors of cardiac events. In subgroup analysis, LV GLS was a significant predictor of cardiac outcome, regardless of the presence of LV dysfunction, the presence of atrial fibrillation, and the type of surgery. Impaired GLS was associated with all-cause mortality (HR: 1.068, 95% CI: 1.003 to 1.136; p = 0.040). ConclusionsGLS appears to be a better predictor of cardiac events all-cause death than conventional parameters. Measuring preoperative GLS is helpful to predict post-operative outcome and determine optimal timing for surgery in patients with severe primary MR.

Global longitudinal strain predicts outcome after MitraClip implantation for secondary mitral regurgitation.

The aim of this study was to assess preoperative determinants, prevalence, and prognostic impact of left ventricular (LV) reverse remodeling (LVRR) in patients with secondary mitral regurgitation (SMR), undergoing MitraClip implantation (MCi). From March 2012 to January 2015, a total of 41 consecutive patients with moderate-to-severe SMR treated successfully with MCi were enrolled. All patients underwent clinical and echocardiographic follow-up after MCi. Global longitudinal strain (GLS) was obtained using two dimensional speckle tracking analysis. A reduction in LV end-systolic volume more than 10% compared with baseline was considered as a marker of LVRR. Patients were divided into two groups according to the presence or absence of LVRR. Cardiac events were defined as the occurrence of cardiac death, rehospitalization for worsening heart failure, and mitral valve surgery. On univariable analysis, EuroSCORE II and GLS were associated with LVRR. On multivariable logistic regression analysis, GLS was the only independent correlate of LVRR (P = 0.004). A receiver operating characteristic curve identified a cutoff value for GLS of -9.25% (P < 0.001) associated with LVRR, with a sensitivity and specificity of 81 and 74%, respectively. New York Heart Failure Association class more than 2 after MCi, absence of LVRR after MCi, and preoperative GLS more than -9.25% were significantly correlated with adverse cardiac events at long-term follow-up. On multivariable logistic regression analysis, GLS was the only independent predictor of composite adverse cardiac events at 2-year follow-up. A worse preoperative GLS predicts no LVRR and is associated with adverse long-term outcome after successful MCi for SMR.

Predicting Left Ventricular Dysfunction after Surgery in Patients with Chronic Mitral Regurgitation: Assessment of Myocardial Deformation by 2-Dimensional Multilayer Speckle Tracking Echocardiography.

Background and ObjectivesThe development of postoperative left ventricular (LV) dysfunction is a frequent complication in patients with chronic severe mitral valve regurgitation (MR) and portends a poor prognosis. Assessment of myocardial deformation enables myocardial contractility to be accurately estimated. The aim of the present study was to evaluate the predictive value of preoperative regional LV contractile function assessment using two-dimensional multilayer speckle-tracking echocardiography (2D MSTE) analysis in patients with chronic severe MR with preserved LV systolic function.Subjects and MethodsForty-three consecutive patients with chronic severe MR with preserved LV systolic function scheduled for mitral valve replacement (MVR) or MV repair were prospectively enrolled. Serial echocardiographic studies were performed before surgery, at 7 days follow-up, and at least 3 months follow-up postoperatively. The conventional echocardiographic parameters were analyzed. Global longitudinal strain (GLS) was obtained quantitatively by 2D MSTE.ResultsThe mean age of patients was 51.7±14.3 years and 25 (58.1%) were male. In receiver-operating characteristic curve analysis, the most useful cutoff value for discriminating postoperative LV remodeling in severe MR with normal LV systolic function was -20.5% of 2D mid-layer GLS. Patients were divided into two groups by the baseline GLS -20.5%. Preoperative GLS values strongly predicted postoperative LV remodeling or LV dysfunction. The postoperative degree of decrease in LV end-diastolic dimension might be an additive predictive factor.ConclusionSTE can be used to predict a decrease in LV function after MVR in patients with chronic severe MR. This promising method could be of use in the clinic when trying to decide upon the optimum time to schedule surgery for such patients.

Assessment of Longitudinal Myocardial Mechanics in Patients with Degenerative Mitral Valve Regurgitation Predicts Postoperative Worsening of Left Ventricular Systolic Function

The optimal timing of mitral valve repair (MVr) in patients with chronic severe degenerative mitral regurgitation (MR) remains controversial and is broadly based on either measurable loss of systolic function, as determined by left ventricular (LV) ejection fraction (LVEF) and/or LV chamber remodeling. The aim of this study was to test the hypothesis that the assessment of LV deformation by speckle-tracking echocardiography might uncover subclinical changes for predicting reduction of LVEF after MVr. One hundred thirty patients (mean age, 57 ± 14 years; 85 men) who underwent MVr for chronic severe degenerative MR were retrospectively identified. Baseline and immediate postoperative transthoracic echocardiography was used to assess global longitudinal strain (GLS), global radial strain, and global circumferential strain before and after MVr. In comparison with baseline, MVr resulted in significant reductions in LVEF (P < .0001) and in GLS (P<.0001). Postoperative change in LVEF was related to the changes in GLS (r= -0.71, P < .0001) and global circumferential strain (r= -0.22, P= .01) but not global radial strain. For the entire group, the presence of a high preoperative GLS magnitude predicted a postoperative reduction in LVEF of >10% (odds ratio, 0.80; P < .001). Furthermore, GLS showed diagnostic value in predicting a reduction in LVEF of >10% with a resulting postoperative LVEF of <50% (area under the curve, 0.93; P < .001). In chronic severe degenerative MR, disproportionately higher LV global longitudinal strain signifies a maladaptive preload-related change that is associated with substantial loss of LVEF immediately after MVr. Preoperative assessment of longitudinal strain may be potentially useful for optimizing the timing of MVr for degenerative MR.

RELATIVE CONTRIBUTION OF AFTERLOAD AND INTERSTITIAL TISSUE FIBROSIS TO PREOPERATIVE LONGITUDINAL FUNCTION IN PATIENTS WITH SEVERE AORTIC STENOSIS: IMPLICATIONS FOR POSTOPERATIVE FUNCTIONAL RECOVERY

Background: Several previous studies have demonstrated that, in patients with severe aortic stenosis (SAS), chronic pressure overload hypertrophy frequently results in reduced longitudinal function as assessed by tissue Doppler or speckle tracking echocardiography (STE). The aim of the present study was to determine the relative contribution of structural (interstitial fibrosis) and functional (afterload) alterations in this process and to evaluate the implications thereof for functional recovery after aortic valve replacement (AVR). Methods: 34 patients with isolated SAS underwent pre-operative resting conventional echocardiography and STE, to calculate end-systolic wall stress (ESS) and to measure global longitudinal strain (GLS) and left ventricular ejection fraction (LVEF). At the time of AVR, a per-operative transmural biopsy was obtained in every patient, to quantify the degree of interstitial fibrosis. Echocardiographic functional parameters were reassessed 6 months after AVR. Results: Compared to age-matched normal controls, SAS patients exhibited significantly reduced GLS (-12.5 ± 3.9% vs -18.2 ± 1.5% p<0.0001) and LVEF (57 ± 13 vs 66 ± 4%, p=0.026). With univariate analysis, pre-operative GLS was found to correlate significantly with LVEF (r=0.70, p<0.0001), interstitial fibrosis (r=-0.60, p=0.0002), LV mass (r=-0.52, p=0.002) and ESS (r=-0.61, p=0.0001). Using stepwise multiple regression analysis, only the degree of interstitial fibrosis and ESS were found to be independent correlates of pre-operative GLS (r=0.74). Interestingly,unstressed pre-operative GLS, extrapolated as GLS at zero stress, correlated well with interstitial fibrosis (r=0.51) and predicted GLS at the 6-months post-operative follow-up (r=0.55). Conclusions: In patients with SAS, reduced longitudinal function results from both excessive afterload and structural tissue alterations (interstitial fibrosis). Unstressed pre-operative GLS was found to be a reasonable correlate of tissue fibrosis and to allow prediction of long term post-operative longitudinal function.

Echocardiographic Predictors of Early Postsurgical Myocardial Dysfunction in Pediatric Patients With Aortic Valve Insufficiency

In chronic aortic insufficiency (AI), left-ventricular (LV) dysfunction must be detected early to allow timely surgery. Strain and strain rate have been used for this purpose in adults, but the value of this method in pediatric AI has not been established. Forty patients with moderate to severe AI were included in this retrospective study. LV function was assessed by strain analysis and conventional echocardiography both before and after surgery. Of the 32 patients with preserved preoperative ejection fraction (EF; >50 %), 8 had postoperative dysfunction (<50 %). Mean conventional indices of global LV systolic performance for the entire cohort of patients with AI were predominantly in the normal range before surgery. Preoperative values for LV global longitudinal strain (GLS) and strain rate (GLSr) were normal. After surgery, there was a significant decrease in shortening and EF. There was a significant decrease from preoperative to postoperative values for both GLS (-16.07 ± 3.82 vs. -11.06 ± 3.88; p < 0.0001) and GLSr (-0.89 ± 0.24 vs. -0.72 ± 0.27; p = 0.0021). A preoperative GLS of -15.3 (AUC = 0.83, CI = 0.69-0.98, p < 0.0001) and a GLSr of -0.79/s (AUC = 0.86, CI = 0.73-0.98, p < 0.0001) were determined to be predictors of early postoperative dysfunction after surgical repair of moderate to severe AI. A preoperative GLS value of ≤-15.3 and GLSr value of -0.79/s or less are predictors of postoperative ventricular dysfunction, which is defined by EF <50 %. GLS and GLSr value determination may be useful as part of the echocardiographic assessment AI and may help determine the optimal timing of surgery in pediatric patient with at least moderate AI.