Strain Evaluation in TAVR—Current Evidence, Knowledge Gaps, and Future Directions
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Purpose of Review
Transcatheter aortic valve replacement (TAVR) has been a paradigm shift for the treatment of patients with severe aortic stenosis (AS). Subclinical cardiac changes in myocardial deformation, not reflected by left ventricular ejection fraction (LVEF), are often present and can be measured by strain imaging. This manuscript will review the current literature and discuss the importance of strain evaluation in TAVR patients.
Strain measurement, especially global longitudinal strain (GLS), has been shown to be associated with outcomes in patients with AS. In addition, GLS assessment prior to and after TAVR appears to correlate with LV functional recovery, symptoms, and the prognosis in these patients; however, evidence is limited to small studies.
With a better understanding of strain evaluation in TAVR patients, this important imaging modality could emerge as a powerful bedside tool to aid in determining the timing of intervention and further improving outcomes.
KeywordsAortic stenosis (AS) Aortic valve replacement (AVR) Global longitudinal strain (GLS) Speckle tracking echocardiography (STE) Subclinical cardiac damage Transcatheter aortic valve replacement (TAVR)
Compliance with Ethical Standards
Conflict of Interest
JLC has investigator invited Research Grant and Consulting (Medtronic Inc). There are no other conflicts of interest.
Human and Animal Rights and Informed Consent
All reported studies with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 6.Chang S-A, Park P-W, Sung K, Lee S-C, Park SW, Lee YT, et al. Noninvasive estimate of left ventricular filling pressure correlated with early and midterm postoperative cardiovascular events after isolated aortic valve replacement in patients with severe aortic stenosis. J Thorac Cardiovasc Surg. 2010;140(6):1361–6.CrossRefPubMedGoogle Scholar
- 7.Dahl JS, Videbæk L, Poulsen MK, Pellikka PA, Veien K, Andersen LI, et al. Noninvasive assessment of filling pressure and left atrial pressure overload in severe aortic valve stenosis: relation to ventricular remodeling and clinical outcome after aortic valve replacement. J Thorac Cardiovasc Surg. 2011;142(3):e77–83.CrossRefPubMedGoogle Scholar
- 10.Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, et al. 2014 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 Practice Guidelines. Circulation. 2014;129(23):e521–643.CrossRefPubMedGoogle Scholar
- 11.Joint Task Force on the Management of Valvular Heart Disease of the European Society of C, European Association for Cardio-Thoracic S, Vahanian A, Alfieri O, Andreotti F, Antunes MJ, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012;33(19):2451–96.CrossRefGoogle Scholar
- 12.Clavel MA, Webb JG, Rodes-Cabau J, Masson JB, Dumont E, De Larochelliere R, et al. Comparison between transcatheter and surgical prosthetic valve implantation in patients with severe aortic stenosis and reduced left ventricular ejection fraction. Circulation. 2010;122(19):1928–36.CrossRefPubMedGoogle Scholar
- 13.Ribeiro HB, Lerakis S, Gilard M, Cavalcante JL, Makkar R, Herrmann HC, et al. Transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis. TOPAS-TAVI Registry. 2018;71(12):1297–308.Google Scholar
- 14.• Ng AC, Delgado V, Bertini M, Antoni ML, van Bommel RJ, van Rijnsoever EP, 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(12):1542–50. The author of this study showed that subclinical cardiac changes might be present in patients with severe AS despite normal LVEF. CrossRefPubMedGoogle Scholar
- 17.Mor-Avi V, Lang RM, Badano LP, Belohlavek M, Cardim NM, Derumeaux G, et al. Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography. J Am Soc Echocardiogr. 2011;24(3):277–313.CrossRefPubMedGoogle Scholar
- 20.• Potter E, Marwick TH. Assessment of left ventricular function by echocardiography: the case for routinely adding global longitudinal strain to ejection fraction. JACC Cardiovasc Imaging. 2018;11(2 Pt 1):260–74. This review appraised the evidence for GLS as a complementary metric to LVEF for incorporation into mainstream clinical practice. CrossRefPubMedGoogle Scholar
- 25.• Ng ACT, Prihadi EA, Antoni ML, Bertini M, Ewe SH, Ajmone Marsan N, Leung DY, Delgado V, Bax JJ Left ventricular global longitudinal strain is predictive of all-cause mortality independent of aortic stenosis severity and ejection fraction. Eur Heart J Cardiovasc Imaging 2017. https://doi.org/10.1093/ehjci/jex189. This article showed GLS is independently associated with all-cause morality in 688 AS patients.
- 26.Alashi A, Mentias A, Abdallah A, Feng K, Gillinov AM, Rodriguez LL, et al. Incremental prognostic utility of left ventricular global longitudinal strain in asymptomatic patients with significant chronic aortic regurgitation and preserved left ventricular ejection fraction. JACC Cardiovasc Imaging 2018;11(5):673–682.Google Scholar
- 28.Ersbøll M, Valeur N, Mogensen UM, Andersen MJ, Møller JE, Velazquez EJ, et al. Prediction of all-cause mortality and heart failure admissions from global left ventricular longitudinal strain in patients with acute myocardial infarction and preserved left ventricular ejection fraction. J Am Coll Cardiol. 2013;61(23):2365–73.CrossRefPubMedGoogle Scholar
- 30.Thavendiranathan P, Poulin F, Lim KD, Plana JC, Woo A, Marwick TH. Use of myocardial strain imaging by echocardiography for the early detection of cardiotoxicity in patients during and after cancer chemotherapy: a systematic review. J Am Coll Cardiol. 2014;63(25 Pt A):2751–68.CrossRefPubMedGoogle Scholar
- 31.Zamorano JL, Lancellotti P, Rodriguez Munoz D, Aboyans V, Asteggiano R, Galderisi M, et al. 2016 ESC Position Paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines: The Task Force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC). Eur J Heart Fail. 2017;19(1):9–42.CrossRefPubMedGoogle Scholar
- 34.• Collier P, Phelan D, Klein A. A test in context: myocardial strain measured by speckle-tracking echocardiography. J Am Coll Cardiol. 2017;69(8):1043–56. This review article appraised STE in a clinical context by providing a critical evaluation of the prognostic and diagnostic insights. Google Scholar
- 35.• Negishi K, Negishi T, Kurosawa K, Hristova K, Popescu BA, Vinereanu D, et al. Practical guidance in echocardiographic assessment of global longitudinal strain. JACC Cardiovasc Imaging. 2015;8(4):489–92. The author of this paper provides essential information about steps of strain measurements. CrossRefPubMedGoogle Scholar
- 45.Staron A, Bansal M, Kalakoti P, Nakabo A, Gasior Z, Pysz P, et al. Speckle tracking echocardiography derived 2-dimensional myocardial strain predicts left ventricular function and mass regression in aortic stenosis patients undergoing aortic valve replacement. Int J Cardiovasc Imaging. 2013;29(4):797–808.CrossRefPubMedGoogle Scholar
- 47.Poulin F, Carasso S, Horlick EM, Rakowski H, Lim KD, Finn H, et al. Recovery of left ventricular mechanics after transcatheter aortic valve implantation: effects of baseline ventricular function and postprocedural aortic regurgitation. J Am Soc Echocardiogr. 2014;27(11):1133–42.CrossRefPubMedGoogle Scholar
- 48.Kamperidis V, Joyce E, Debonnaire P, Katsanos S, van Rosendael PJ, van der Kley F, et al. Left ventricular functional recovery and remodeling in low-flow low-gradient severe aortic stenosis after transcatheter aortic valve implantation. J Am Soc Echocardiogr. 2014;27(8):817–25.CrossRefPubMedGoogle Scholar
- 50.Dinh W, Nickl W, Smettan J, Kramer F, Krahn T, Scheffold T, et al. Reduced global longitudinal strain in association to increased left ventricular mass in patients with aortic valve stenosis and normal ejection fraction: a hybrid study combining echocardiography and magnetic resonance imaging. Cardiovasc Ultrasound. 2010;8:29.CrossRefPubMedPubMedCentralGoogle Scholar
- 53.Giannini C, Petronio AS, Talini E, De Carlo M, Guarracino F, Grazia M, et al. Early and late improvement of global and regional left ventricular function after transcatheter aortic valve implantation in patients with severe aortic stenosis: an echocardiographic study. Am J Cardiovasc Dis. 2011;1(3):264–73.PubMedPubMedCentralGoogle Scholar
- 54.Schattke S, Baldenhofer G, Prauka I, Zhang K, Laule M, Stangl V, et al. Acute regional improvement of myocardial function after interventional transfemoral aortic valve replacement in aortic stenosis: a speckle tracking echocardiography study. Cardiovasc Ultrasound. 2012;10:15.CrossRefPubMedPubMedCentralGoogle Scholar
- 55.Delgado M, Ruiz M, Mesa D, de Lezo Cruz Conde JS, Pan M, Lopez J, et al. Early improvement of the regional and global ventricle function estimated by two-dimensional speckle tracking echocardiography after percutaneous aortic valve implantation speckle tracking after CoreValve implantation. Echocardiography (Mount Kisco, NY). 2013;30(1):37–44.CrossRefGoogle Scholar
- 63.Bauer F, Coutant V, Bernard M, Stepowski D, Tron C, Cribier A, et al. Patients with severe aortic stenosis and reduced ejection fraction: earlier recovery of left ventricular systolic function after transcatheter aortic valve implantation compared with surgical valve replacement. Echocardiography (Mount Kisco, NY). 2013;30(8):865–70.CrossRefGoogle Scholar
- 65.Becker M, Kramann R, Dohmen G, Luckhoff A, Autschbach R, Kelm M, et al. Impact of left ventricular loading conditions on myocardial deformation parameters: analysis of early and late changes of myocardial deformation parameters after aortic valve replacement. J Am Soc Echocardiogr. 2007;20(6):681–9.CrossRefPubMedGoogle Scholar
- 72.Klaeboe LG, Haland TF, Leren IS, Ter Bekke RMA, Brekke PH, Rosjo H, et al. Prognostic value of left ventricular deformation parameters in patients with severe aortic stenosis: a pilot study of the usefulness of strain echocardiography. J Am Soc Echocardiogr. 2017;30(8):727–35.e1.CrossRefPubMedGoogle Scholar