Assessing Function by Echocardiography in VHD Asymptomatic Severe Organic MR. Dr. Julien Magne, PhD Sart Tilman Liège, BELGIUM

Transcription

1 Assessing Function by Echocardiography in VHD Asymptomatic Severe Organic MR Dr. Julien Magne, PhD Sart Tilman Liège, BELGIUM

2 Conflict of Interest Disclosure None

3 Why to assess LV function in asymptomatic severe primary MR? How to assess LV function in asymptomatic severe primary MR?

4 Determinants of LV function in MR in MR Preload Contractility Synchronicity Normal valvular function Stroke volume Afterload Heart rate Cardiac output

5 Assessment of LV Systolic Function Parameters LV dimensions LV ejection fraction LV stroke volume LV contractility (WMSI) LV longitudinal function LV circumferential function LV radial function LV torsion Modalities M-mode, 2D M-mode, 2D, 3D, RT3D 2D+Doppler, 3D 2D, 3D, RT3D M-Mode, TDI, Color TDI, 2D Speckle tracking, 3D Speckle tracking 2D Speckle tracking, 3D Speckle tracking 2D Speckle tracking, 3D Speckle tracking 2D Speckle tracking, 3D Speckle tracking

6 3 Steps of Evaluation Indication for Surgery: ESC and ACC/AHA Guidelines Severe MR Class: IC & IB Asymptomatic LV function Bonow et al. Circulation, 2006 Vahanian et al. Eur Heart J, 2007

7 Impact of LV Dilatation on Survival MIDA registry 739 patients with flail leaflet, follow-up: 6.1±3.7 years Conservative treatment Surgical treatment Tribouilloy et al. JACC, 2009;54: Editorial: Pierard and Magne, JACC, Hazard Ratio Only 33% of asymptomatic pts with LVESD >40mm 40 or 22 mm/m² LV ESD (mm)

8 Postoperative Survival, % Impact of LVEF on Postoperative Outcome LVEF 60% Excellent survival as compared to reference population LVEF 60% LVEF 50-60% LVEF <50% Follow-up, years 72±4% 53±9% 32±12% p= Enriquez-Sarano et al. Circulation, 1994

9 LVEF in Patients with MR LVEF= Regurgitant fraction + Forward ejection fraction LV EDV = 250 ml LV ESV = 50 ml LVEF = 80% Reg. F = 56% Forward EF= 24%

10 Strain and Strain Rate Imaging Longitudinal Shortening Radial Thickening Circumferential Shortening

11 2D Speckle Tracking GLS= -24.3%

12 3D Speckle Tracking Quantification: - Longitudinal strain - Circumferential strain - Radial strain - LV volumes - LVEF - LV mass

13 LV Longitudinal Function: Color TDI Mitral Annulus Tracking

14 Lisi et al. Int J Card, 2010 LV Longitudinal Function M-Mode and TDI

15 Predictors of Postoperative LV Systolic Dysfunction Preoperative useful of LV Longitudinal function 62 chronic severe organic MR 75% of NYHA class I-II MV repair 2 groups (Postop LVEF >50%) Marciniak et al. Eur JTCS, 2011

16 Predictors of Postoperative LV Systolic Dysfunction Preoperative useful of LV Longitudinal function p< p< p< p< Marciniak et al. Eur JTCS, 2011

17 Global Longitudinal strain, % LV Longitudinal Function and BNP 135 asymptomatic moderate degenerative MR Normal LV systolic function From CHU Sart Tilman, Liege Belgium and Laval Hospital, Quebec, Canada Magne, Mahjoub, Pibarot, Piérard and Lancellotti, ESC, LVCR+ LVCR BNP, pg/ml r=-0.70 p< Multivariate analysis GLS: β=-4.2±0.5; p<0.0001

18 Cardiac Event-free Survival, % LV Longitudinal Function and Outcome n=135 GLS >20% 66±7% GLS <20% 28±8% p< Follow-up, months In asymptomatic degenerative MR, reduced LV longitudinal function is associated with 3-fold increase in risk of cardiac-event. Adjusted HR=3.3 ( ) p=0.03 Magne, Mahjoub, Pibarot, Piérard and Lancellotti, ESC, 2011

19 LV Torsion: The floorcloth effect Diastole Systole (clockwise torsion ) (counterclockwise torsion)

20 Impact of MR on LV Torsion 35 patients with chronic organic MR (moderate to severe) compared to 30 age-matched healty controls MR patients Controls Borg et al. Heart, 2008 Chronic MR results in significant delay and slowing of LV untwisting MR severity is correlated with torsional parameters: Early LV dysfunction?

21 Impact of MR on LV Torsion: Biphasic Pattern Severe MR and normal LV systolic function demonstrated the lowest LV rotational profile: early subclinical LV systolic dysfunction Moderate MR revealed the highest rotational profile: hyperdynamic or supranormal LV systolic function Moustafa et al. Eur J Echo, 2011 Borg et al. Eur J Echo, 2010 Biphasic pattern also in LV diastolic function?

22 Asymptomatic MR and LV Contractile Reserve LV contractile reserve is the best predictor of postop. LV systolic dysfunction and exercise capacity Lancellotti et al. JASE, 2008 Madaric et al. Am H J, 2007

23 Ex-induced changes in GLS, % Exercise-induced Changes in LVEF and GLS % r=0.15; p=0.13 LVEF >4% 31% Ex-induced changes in LVEF, % GLS >2% 35% 16% 1/3 of discrepancy Magne, Mahjoub, Pibarot, Piérard and Lancellotti, ESC, 2011 From 2 centers: asymptomatic primary MR (n=112, 60% of severe), preserved LV function between the 2 methods

24 Cardiac Event-free Survival, % Impact of LVCR on Outcome Cardiac Event-free Survival, % LV contractile reserve using GLS 74±8% 68±7% 45±8% 42±8% p=0.003 CR Follow-up, months Adjusted HR=2 ( ) p=0.04 CR LV contractile reserve using LVEF p= ±8% 63±8% 61±7% 50±8% Follow-up, months CR+ CR- Adjusted HR=1.22 ( ) p=0.23 Magne, Mahjoub, Pibarot, Piérard and Lancellotti, ESC, 2011

25 Take Home Message The management of asymptomatic patients with severe organic MR requires the evaluation of LV function. Symptoms occur usually before LV systolic dysfunction (as assessed as recommended by current guidelines). Resting echocardiography should include the evaluation of LV longitudinal function; LV Torsion parameters are promising. The evaluation of LV contractile reserve may be useful for risk stratification.

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27 Ex-induced changes in GLS, % Cardiac Event-free Survival, % Asymptomatic MR and LV Contractile Reserve 1/3 of discrepancy between the 2 methods LVEF >4% % 31% % 16% r=0.15; p= Ex-induced changes in LVEF, % GLS >2% LVCR: useful for risk stratification LVCR- 33±9% p=0.003 n=112 LVCR Follow-up, months 67±7% Adjusted HR=2 ( ) p=0.04 Magne, Mahjoub, Pibarot, Piérard and Lancellotti, ESC, 2011