Aortic valve Stenosis: Insights in the evaluation of LV function. Erwan DONAL Cardiologie CHU Rennes

Transcription

1 Aortic valve Stenosis: Insights in the evaluation of LV function Erwan DONAL Cardiologie CHU Rennes

2 Preload Afterload Myocardial Fiber Shortening Circumferential Longitudinal Mechanical Power Circumferential Thickening Longitudinal BLOOD PRESSURE EJECTION of Blood Geometry Dumesnil et al. Circulation 1979 & 1982

3 Aortic Valve stenosis Myocardial Function & Aortic Valve Stenosis Increase afterload Arterial, small arteries resistance Its characterization is extremely important especially in low flow & low gradient AoS LV EF should be > 60% Concentric Hypertrophy Explored by: Echo, M-mode Speckle tracking Cardiac MR Fibrosis, decrease in diastolic and systolic function

4 AoV replacement x2/10 years Prevalence of AoS supposed to double in the next 20 y. Myocytes enlargment, increase in wall thickness to restore the wall stress but ultimately. maladaptative Journal of the American College of Cardiology Volume 60, Issue

5 Event-free survival curves in patients with appropriate or inappropriately high LV mass. Cioffi G et al. Heart 2011;97:

6 Severe aortic stenosis without LV Hypertrophy? 10% of patients with severe AS: NO LVH (mass); 4% : NO macroscopic signs of myocardial adaptation to the pressure overload Small body size was independently associated Seiler, Jenni. Heart 1996

7 Longitudinal Radial Circumferential LV Frame 1 Frame 2 Normal Values: LONG -20% Circ -20% Radial 40% leaflet DEFORMATION IMAGING ESSENTIALLY FOR THE ROBUST ASSESSMENT OF LV LONGITUDINAL FUNCTION

8

9 experimental 2D-S Longitudinal (%) y = 0,09x - 16,8 R = 0,61, p<0,001 SEE = 25,0 Longitudinal 0 w all stress (kdynes.m²) Baseline release mmhg ,2+-2,3-6,5+-3,2-5,8+-3, Donal et al. EJE 2009 Longitudinal 2D-S -14,6+-3,5

10 Severe aortic valve stenosis with Mean Pr Gradient = 83 mm Hg Global Longitudinal Strain -14% Post TAVI: Mean P Gradient 7.4 mmhg Global Longitudinal Strain-18%

11 In clinical practice, what does the afterload on LV functions? Clinical data

12 radial Circumf. Longit.

13 (1) LV longitudinal myocardial strain is reduced in patients with LV concentric hypertrophy; (2) the extent of longitudinal strain impairment is related to larger LV mass index, higher degree of concentric remodelling and more severe Ao stenosis severity. In guidelines, LV EF is the only parameter considered: but LVEF markedly underestimates the extent of myocardial systolic impairment in the presence of LV concentric hypertrophy (AS patients). Cramariuc D, et al.heart 2010;96: Poulsen SH, et al. J Am Soc Echocardiogr 2007;20: Takeda S, et al. Heart 2001;86:52 6 Pibarot et al. Heart 2010; 96 : 95-96

14 Severe Asymptomatic AoS Patients Lafitte, S. et al.

15 Prognostic value of Basal Longitudinal Strain in patients with severe asymptomatic AoS Lafitte, S. et al.

16 Prognostic markers in asymptomatic severe AS : integrated approach 173 patients with severe AoS and no symptoms Mean AVA: 0.45 ± 0.09 cm²/m² (range 0.2 to 0.6) Mean pressure gradient: 46 ± 14 mmhg (25 to 86) Mean LVEF: 67 ± 7% (range 55 to 84) Mean follow-up 20 ± 19 months (range 4 to 102) Predefined end-points: 74 patients 6 deaths AVR required in 57 pts Symptoms but no AVA in 11 pts Lancellotti, Donal,et al. Heart 2010

17 Prediction of Cv Events including AoV replacement in patents with severe asymptomatic AoS Peak aortic velocity 4.4 m.s -1 Zva 4.9 mmhg.ml -1.m -2 Longitudinal strain 15.9 % Ind. LA area 12.2 cm 2 /m 2 HR= 1.7, p=0.027 HR= 1.9, p=0.013 HR= 2.2, p=0.003 HR= 2.8, p= Hazard-ratio Heart 2010 Adjustment for gender, systemic arterial compliance, E-wave, E/A ratio and response to exercise (abnormal vs. normal)

18 N=146 low (GLS > 15%) Adda J et al. Circ Cardiovasc Imaging 2012;5:27-35 Kearney L et al. Eur Heart J Cardiovasc Imaging 2012;13:

19

20 Rennes, 195 Asymptomatic AoS patients Global Longitudnal Strain (%)

21

22 IBS Myocardial fibrosis Myocardial fibrosis 35 patients followed 1-year Predictive value of IBS for LV anatomical and functional remodeling after Ao Valve Replacement Di Bello V et al. Circulation. 2004;110:

23 Longitudinal function decrease 58 patients / 9 months Longitudinal systolic function appear to indicate sensitively both the severity of myocardial fibrosis and the clinical outcome Weidemann F et al. Circulation. 2009;120:

24 Direct relationship between myocardial fibrosis and longitudinal function especially in the basal segments Weidemann F et al. Circulation. 2009;120:

25

26 Bull S et al. Heart 2013;99:

27 CONCLUSIONS Subtle, but clinically relevant, changes in LV contractility can be detected by 2D-S especially by its Longitudinal component. Longitudinal Strain is more than LVEF related to prognosis and linked to myocardial hypertrophy and fibrosis

28 Join us in Istanbul! December 2013 Main Themes Heart Failure Imaging in Interventional Cardiology Important deadlines Abstract Submission 31 May 2013 Early Registration 30 September 2013 Speaker

29 Reco ESC 2012

30 What about the LV Myocardial function from BEFORE to AFTER an Aortic Valve Replacement?

31 73 severe AS patients (65+13 years; aortic valve area cm2) with preserved LVEF (61+11%), before and 17 months after AVR Delgado et al. Eur Heart J 2009; 30: 3037

32

33