Author + information
- Received January 3, 2017
- Revision received February 21, 2017
- Accepted February 23, 2017
- Published online May 7, 2018.
- Alaa Alashi, MD,
- Amgad Mentias, MD,
- Amjad Abdallah, MD,
- Ke Feng, MD,
- A. Marc Gillinov, MD,
- L. Leonardo Rodriguez, MD,
- Douglas R. Johnston, MD,
- Lars G. Svensson, MD, PhD,
- Zoran B. Popovic, MD, PhD,
- Brian P. Griffin, MD and
- Milind Y. Desai, MD∗ ()
- ↵∗Address for correspondence:
Dr. Milind Y. Desai, Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, Ohio 44195.
Objectives This study sought to examine the prognostic utility of left ventricular (LV) global longitudinal strain (GLS) in asymptomatic patients with ≥III+ aortic regurgitation (AR), an indexed LV end-systolic dimension of <2.5 cm/m2, and preserved left ventricular ejection fraction (LVEF).
Background Management of asymptomatic patients with severe chronic AR and preserved LVEF is challenging and is typically based on LV dimensions.
Methods We studied 1,063 such patients (age 53 ± 16 years; 77% men) seen between 2003 and 2010 (excluding those with symptoms, obstructive coronary artery disease, acute AR/dissection, aortic/mitral stenosis, more than moderate mitral regurgitation, and previous cardiac surgery). Society of Thoracic Surgeons (STS) score was calculated. The primary endpoint was mortality. Average resting LV-GLS was measured offline on 2-, 3-, and 4-chamber views using Velocity Vector Imaging (Siemens, Malvern, Pennsylvania).
Results Mean STS score, LVEF, LV-GLS, and right ventricular systolic pressure were 4.4 ± 5.0%, 57.0 ± 4.0%, −19.5 ± 0.2%, and 31.0 ± 9.0 mm Hg, respectively. In total, 671 patients (63%) underwent aortic valve surgery at a median of 42 days after the initial evaluation. At 6.8 ± 3.0 years, 146 patients (14%) had died. On multivariable Cox survival analysis, LV-GLS (hazard ratio [HR]: 1.11), STS score (HR: 1.51), indexed LV end-systolic dimension (HR: 0.50), right ventricular systolic pressure (HR: 1.33), and aortic valve surgery (HR: 0.35) were associated with longer term mortality (all p < 0.001). Sequential addition of LV-GLS and aortic valve surgery improved the C-statistic for longer term mortality for the clinical model (STS score + right ventricular systolic pressure + indexed LV end-systolic dimension) from 0.61 (95% confidence interval [CI]: 0.51 to 0.72) to 0.67 (95% CI: 0.54 to 0.87) and to 0.77 (95% CI: 0.63 to 0.90), respectively (p < 0.001 for both). A significantly higher proportion (log-rank p = 0.01) of patients with LV-GLS worse than median (−19.5%) died versus those with an LV-GLS better than median (86 of 513 [17%] vs. 60 of 550 [11%]). The risk of death at 5 years significantly increased with an LV-GLS of worse than −19%.
Conclusions In asymptomatic patients with ≥III+ chronic AR and preserved LVEF, worsening LV-GLS was associated with longer term mortality, providing incremental prognostic value and improved reclassification.
Dr. Desai is supported in part by Haslam Family Endowed Chair in Cardiovascular Medicine, and portions of this research were funded from their philanthropic gift. Dr. Gillinov is on the Speakers Bureau for Atricure, Edwards Lifesciences, Medtronic, and St. Jude Medical; and has equity stake in Pleuraflow. Dr. Johnston is a consultant for Edwards Lifesciences, St. Jude, KEF Holdings, and Interactive Visual Health Record. Dr. Desai is a consultant for Myokardia, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 3, 2017.
- Revision received February 21, 2017.
- Accepted February 23, 2017.
- 2018 American College of Cardiology Foundation
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