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Impact of left ventricular global longitudinal strain on outcome after transcatheter aortic valve implantation in patients with severe aortic valve stenosis

https://doi.org/10.1007/s00392-024-02406-5

Lisa Voigtländer-Buschmann (Hamburg)1, C. Kellner (Hamburg)2, L. Waldschmidt (Hamburg)1, D. Grundmann (Hamburg)2, S. Ludwig (Hamburg)2, I. von der Heide (Hamburg)2, L. E. M. Hannen (Hamburg)2, T. J. Demal (Hamburg)3, O. Bhadra (Hamburg)3, N. Schofer (Hamburg)1, D. Kalbacher (Hamburg)1, H. Reichenspurner (Hamburg)3, S. Blankenberg (Hamburg)2, L. Conradi (Hamburg)3, A. Schäfer (Hamburg)3, M. Seiffert (Hamburg)2, C. Sinning (Hamburg)4

1Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland; 2Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; 3Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland; 4Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Kardiologie Hamburg, Deutschland

 

Background: Left ventricular global longitudinal strain (GLS) analysis is a sensitive tool for early detection of changes in left ventricular function, preceding reductions in of  left ventricular ejection fraction (LVEF). Despite its potential, GLS is not routinely used to evaluate patients with severe aortic valve stenosis (AS) or in post-transcatheter aortic valve implantation (TAVI) echocardiographic evaluations. This study aims to investigate the impact of left ventricular GLS on outcomes after TAVI and identify patients most likely to benefit in terms of left ventricular function improvement. 

 

Methods and Results: Left ventricular GLS was retrospectively determined in 674 patients receiving TAVI for severe AS between 2019 and 2022. Patients stratified into four groups based on echocardiographic phenotypes: A: patients with preserved systolic LV-EF ≥50% and mean transaortic gradient (dPmean) ≥40 mmHg (n=239), B: patients with paradoxical low flow low gradient (LF/LG) AS (LV-EF ≥50%, dPmean <40 mmHg)(n=209), C: patients with LF/LG AS (EF<50%, dPmean<40 mmHg)(n=155) and D: patients with reduced LVEF (<50%) and dPmean ≥40 mmHg (n=71). 

Overall, GLS was -12.2 before TAVI and -12.9 after TAVI. Pre-procedural GLS was significantly higher in patients with preserved LVEF (Group A: -13.8 and Group B: -13.9) compared to patients with reduced LVEF (Group C: -8.1 and Group D: -10.0), irrespective of the transaortic gradient (p<0.001). Patients in Group D exhibited the greatest GLS improvement after TAVI (Delta GLS -2.5), followed by patients in Group C (Delta GLS: -1.3). Conversely, GLS did not significantly improve in patients in Group A (Delta GLS: -0.4) and in Group B (Delta GLS: 0; p<0.001). Mortality rates at 30 days, one year, and three years were 2.4%, 15.9%, and 31.6%, respectively. At a median follow-up of 1.95 years (1.46, 2.05), mortality was over twofold higher in patients in Groups B and C compared to those in Groups A and D (26.2% and 26.4% versus 12.1% and 12.9%; p<0.001, see figure).


Conclusion:

Patients in Group D had the highest potential for improvement in LV function measured by GLS. Despite reduced LV function, this group exhibited a mortality rate comparable to patients with preserved LV function and a high transaortic gradient, while mortality was over twofold higher in patients with a low transaortic gradient and preserved or reduced LV function.

 

Figure: Mortality in patients with high gradient aortic stenosis with preserved left ventricular ejection fraction (Group A), paradoxical low flow-low gradient aortic stenosis (Group B), low flow-low gradient aortic stenosis (Group C) and high gradient aortic stenosis with reduced left ventricular ejection fraction (Group D)

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