The signifi cance of global longitudinal strain of left ventricular in the classifi cation of stages of aortic stenosis based on the extravalvular cardiac damage

Severe aortic stenosis (AS) is characterized not only by degenerative changes in the aortic valve but also by extravalvular cardiac damage. Recently, a new staging classifi cation of AS has been proposed based on the extent of cardiac damage, as well as its modifi ed variants with the addition of a measure of global longitudinal strain of the left ventricular (GLS LV), as an earlier predictor of preclinical LV systolic dysfunction.
Aim. To evaluate the signifi cance of GLS LV in the staging classifi cation of AS based on the extent of cardiac damage according to a multidisciplinary hospital.
Мaterials and methods. 66 patients with severe AS with available GLS LV by speckle tracking echocardiography were selected and analyzed retrospectively.
Results. Patients were categorized according to cardiac damage on ECHO: stage 0 was determined in 2 (3%) patients; stage 1 — 10 (15%), stage 2 — 41 (62%), stage 3 — 13 (20%). The use of staging classifi cation of AS with addition of GLS LV quintiles led to patient reclassifi cation. Thus, stage 4 included patients from stage 2 and stage 3 cardiac damage.
Conclusions. In patients with severe AS, the adding the GLS LV to the routine ECHO can help to more accurately determine the stages of AS and make the right decision on the management tactics of such patients.

1. Mursalimova A.I., Gendli G.E., Storozhakov G.I. Features of the course and diagnosis of aortic stenosis. Cardiology News. 2013;1;10–14.

2. Osnabrugge R.L., Mylotte D., Head S.J., Van Mieghem N.M., Nkomo V.T., LeReun C.M. et al. Aortic stenosis in the elderly: disease prevalence and number of candidates for transcatheter aortic valve replacement: a meta-analysis and modeling study. J. Am. Coll. Cardiol. 2013;62(11):1002–1012. DOI: 10.1016/j.jacc.2013.05.015. Epub 2013 May 30. PMID: 23727214

3. Nishimura R.A., Otto C.M., Bonow R.O. et al. // AHA/ACC focused update of the 2017 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J. Am. Coll. Cardiol. 2017;135(25):1159–95. DOI: 10.1161/CIR.0000000000000503

4. Kampaktsis P.N., Kokkinidis D.G., Wong S.C., Vavuranakis M., Skubas N.J., Devereux R.B. The role and clinical implications of diastolic dysfunction in aortic stenosis. Heart. 2017;103(19):1481–1487. DOI: 10.1136/heartjnl-2017-311506. Epub 2017 Jul 6. PMID: 28684437

5. Barbanti M., Webb J.G., Hahn R.T., Feldman T., Boone R.H., Smith C.R. et al. Placement of Aortic Transcatheter Valve Trial Investigators. Impact of preoperative moderate/severe mitral regurgitation on 2-year outcome after transcatheter and surgical aortic valve replacement: insight from the Placement of Aortic Transcatheter Valve (PARTNER) Trial Cohort A. Circulation. 2013;128(25):2776–84. DOI: 10.1161/CIRCULATIONAHA.113.003885. Epub 2013 Oct 23. PMID: 24152861

6. Asami M., Stortecky S., Praz F., Lanz J., Raber L., Franzone A. et al. Prognostic value of right ventricular dysfunction on clinical outcomes after transcatheter aortic valve replacement. J. Am. Coll. Cardiol. Imaging. 2019;12:577–87. DOI: 10.1016/j.jcmg.2017.12.015

7. Généreux P., Pibarot P., Redfors B., Mack M.J., Makkar R.R., Jaber W.A.et al. Staging classifi cation of aortic stenosis based on the extent of cardiac damage. Eur. Heart J. 2017;38(45):3351–3358. DOI: 10.1093/eurheartj/ehx381. PMID: 29020232; PMCID: PMC5837727

8. Tastet L., Tribouilloy C., Maréchaux S., Vollema E.M., Delgado V., Salaun E.et al. Staging cardiac damage in patients with asymptomatic aortic valve stenosis. J. Am. Coll. Cardiol. 2019;74(4):550–563. DOI: 10.1016/j.jacc.2019.04.065. PMID: 31345430

9. Vollema E.M., Amanullah M.R., Prihadi E.A.,. Ng A. C.T, van der Bijl P., Sin Y.K. et al. Incremental value of left ventricular global longitudinal strain in a newly proposed staging classifi cation based on cardiac damage in patients with severe aortic stenosis, Eur. Heart J. Cardiovasc. Imaging. 2020;21(11);1248–1258. DOI: https://doi.org/10.1093/ehjci/jeaa220

10. Roberto M. Lang, Luigi P. Badano, Victor Mor-Avi et al. Recommendations for Cardiac Chamber Quantifi cation by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J. Am. Soc. Echocardiogr. 2015;28:1–39. DOI https://doi.org/10.1016/j.echo.2014.10.003

11. Nagueh S.F., Smiseth O.A., Appleton C.P., Byrd B.F. 3rd, Dokainish H., Edvardsen T. et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur. Heart. J. Cardiovasc. Imaging. 2016;17(12):1321–1360. DOI: 10.1161/JAHA.119.014682

12. Arnold C. T. Ng, Edgard A. Prihadi, M. Louisa Antoni, Matteo Bertini, See Hooi Ewe, Nina Ajmone Marsan, Dominic Y. Leung, Victoria Delgado, Jeroen J. Bax. Left ventricular global longitudinal strain is predictive of all-cause mortality independent of aortic stenosis severity and ejection fraction, European Heart Cardiovasc. Imaging. 2018;19(8);859–867. DOI: https://doi.org/10.1093/ehjci/jex189.

13. Kearney L.G., Lu K., Ord M., Patel S.K., Profi tis K., Matalanis G., Burrell L.M., Srivastava P.M. Global longitudinal strain is a strong independent predictor of all-cause mortality in patients with aortic stenosis. Eur. Heart J. Cardiovasc. Imaging. 2012;13(10):827–33. DOI: 10.1093/ehjci/jes115. Epub 2012 Jun 26. PMID: 22736713.

14. Dusenbery S.M., Lunze F.I., Jerosch-Herold M., Geva T., Newburger J.W., Colan S.D., Powell A.J. Left Ventricular Strain and Myocardial Fibrosis in Congenital Aortic Stenosis. Am. J. Cardiol. 2015 Oct 15;116(8):1257–62. DOI: 10.1016/j.amjcard.2015.07.042. Epub 2015 Jul 28. PMID: 26343231.

15. Weidemann F., Herrmann S., Störk S., Niemann M., Frantz S., Lange V., Beer M., Gattenlöhner S., Voelker W., Ertl G., Strotmann J.M. Impact of myocardial fi brosis in patients with symptomatic severe aortic stenosis. Circulation. 2009;120(7):577–84. DOI: 10.1161/CIRCULATIONAHA.108.847772. Epub 2009 Aug 3. PMID: 19652094

16. Arnold C. T. Ng A.C., Delgado V., Bertini M., Antoni M.L., van Bommel R.J., van Rijnsoever E.P. et al. Alterations in multidirectional myocardial functions in patients with aortic stenosis and preserved ejection fraction: a two-dimensional speckle tracking analysis. Eur. Heart J. 2011;32:1542–50. DOI: 10.1093/eurheartj/ehr084

17. Abduch M.C., Alencar A.M., Mathias W.Jr., Vieira M.L. Cardiac mechanics evaluated by speckle tracking echocardiography. Arq. Bras. Cardiol. 2014;102(4):403–12. DOI: 10.5935/abc.20140041

18. Magne J., Cosyns B., Popescu B.A., Carstensen H.G., Dahl J., Desai M., Kearney L., Marwick T., Sato K., Takeuchi M., Zito C., Mohty D., Lancellotti P., Habib G. Distribution and prognostic signifi cance of left ventricular global longitudinal strain in asymptomatic signifi cant aortic stenosis: an individual participant data meta-analysis. J. Am. Coll. Cardiol. Img. 2019(12);84–92. DOI: 10.1016/j.jcmg.2018.11.005