Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.
J Am Soc Echocardiogr. 2022 Jul;35(7):692-702.e8. doi: 10.1016/j.echo.2021.10.018. Epub 2022 Mar 25.
Whether automated left ventricular global longitudinal strain (LVGLS) is associated with outcomes in patients with asymptomatic aortic regurgitation (AR) is unknown. The aim of this study was to explore the impact of automated LVGLS on survival and compare it with conventional left ventricular (LV) parameters in patients with chronic asymptomatic AR.
LVGLS (presented as an absolute value) was measured using fully automated two-dimensional strain software in consecutive patients with isolated chronic moderate to severe or greater AR between 2004 and 2020; the incremental value of LVGLS was assessed. Limited correction of endocardial border tracking was performed if needed.
Of 550 asymptomatic patients (mean age, 60 ± 17 years; 86% men), average LVGLS was 17 ± 3% (first and second tertiles, 15.8% and 18.5%). In 16% of cases, tracking border was partially corrected; average time for analysis was 25 ± 5 sec. At a median of 4.8 years (interquartile range, 1.5-9.9 years), 87 patients had died (19 died after aortic valve surgery). Separate multivariable models adjusted for age, sex, Charlson index, AR severity, and time-dependent aortic valve surgery demonstrated that LV ejection fraction (hazard ratio [HR] per 10%, 0.9), LV end-systolic volume index (LVESVi; HR per 5 mL/m, 1.08) and LVGLS (HR per unit, 0.87) were independently associated with death (P ≤ .018 for all); however, LVGLS remained statistically significant (HR: 0.86-0.9; P ≤ .007) when compared head-to-head with LV ejection fraction, LVESVi, and LV end-systolic dimension index. The association of LVGLS and mortality was consistent across all subgroups (P for interaction ≥ .08 for all). Spline curves showed that continuous risk for death rose at LVGLS < 15%. Those with LVGLS < 15% had a 2.6-fold risk for death (95% CI, 1.54-4.23) while those with LVGLS < 15% plus LVESVi ≥ 45 mL/m had 3.96-fold risk (95% CI, 1.94-8.03).
In this large cohort of asymptomatic patients with moderate to severe or greater AR, automated LVGLS was feasible, efficient, and independently associated with death in head-to-head comparisons with conventional LV ejection fraction, LV end-systolic dimension index, and LVESVi. An automated LVGLS threshold of <15% alone or combined with LVESVi ≥ 45 mL/m was significantly associated with increased mortality risk and may be considered in early surgery decision-making.
自动化左心室整体纵向应变（LVGLS）是否与无症状主动脉瓣反流（AR）患者的结局相关尚不清楚。本研究旨在探讨自动化 LVGLS 对生存的影响，并与慢性无症状 AR 患者的传统左心室（LV）参数进行比较。
在 2004 年至 2020 年间，连续纳入患有孤立性慢性中重度或以上 AR 的患者，使用全自动二维应变软件测量 LVGLS（以绝对值表示）；评估 LVGLS 的增量值。如果需要，将对心内膜边界跟踪进行有限的校正。
在 550 名无症状患者中（平均年龄 60±17 岁，86%为男性），平均 LVGLS 为 17±3%（第一和第二三分位数分别为 15.8%和 18.5%）。在 16%的病例中，跟踪边界部分得到了校正；平均分析时间为 25±5 秒。在中位数为 4.8 年（四分位间距，1.5-9.9 年）的随访中，87 例患者死亡（19 例在主动脉瓣手术后死亡）。分别调整年龄、性别、Charlson 指数、AR 严重程度和时间依赖性主动脉瓣手术的多变量模型表明，左心室射血分数（每增加 10%的风险比[HR]，0.9）、左心室收缩末期容积指数（LVESVi；每增加 5mL/m 的 HR，1.08）和 LVGLS（每单位的 HR，0.87）与死亡独立相关（所有 P 值均<.018）；然而，当与左心室射血分数、LVESVi 和左心室收缩末期内径指数进行头对头比较时，LVGLS 仍然具有统计学意义（HR：0.86-0.9；P 值均<.007）。LVGLS 与死亡率的相关性在所有亚组中均一致（交互检验 P 值均>.08）。样条曲线显示，LVGLS<15%时，死亡风险持续升高。LVGLS<15%的患者死亡风险增加 2.6 倍（95%CI，1.54-4.23），而 LVGLS<15%且 LVESVi≥45mL/m 的患者死亡风险增加 3.96 倍（95%CI，1.94-8.03）。
在这一大群患有中重度或以上 AR 的无症状患者中，自动化 LVGLS 是可行的、有效的，并且与传统的左心室射血分数、左心室收缩末期内径指数和 LVESVi 进行头对头比较时，与死亡独立相关。LVGLS<15%的自动化阈值单独或与 LVESVi≥45mL/m 结合使用与更高的死亡率风险显著相关，可能有助于早期手术决策。
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