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Left ventricular myocardial work in patients with high gradient severe symptomatic aortic stenosis
Session:
CO 06 - Valvulopatias
Speaker:
Gustavo Sá Mendes
Congress:
CPC 2021
Topic:
F. Valvular, Myocardial, Pericardial, Pulmonary, Congenital Heart Disease
Theme:
15. Valvular Heart Disease
Subtheme:
15.1 Valvular Heart Disease – Pathophysiology and Mechanisms
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Gustavo Sá Mendes; João Abecasis; Sérgio Maltez; Sara Guerreiro; Pedro Freitas; Eduarda Horta; Telma Lima; Regina Ribeiras; Maria João Andrade; Nuno Cardim; Vitor Gil
Abstract
<p style="margin-right:-38px; text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:10.0pt">Background: </span></strong><span style="font-size:10.0pt">Left ventricular myocardial work (LVMW) is a novel method to evaluated left ventricular (LV) function using pressure-strain loops. It might correct global longitudinal strain (GLS) for afterload, being eventually useful to assess whether GLS reduction is due to reduced contractility (reflected as reduced myocardial work) or increased afterload (reflected as increased myocardial work). </span></span></span></p> <p style="margin-right:-38px; text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:10.0pt">Aim: </span></strong><span style="font-size:10.0pt">to describe indices of LVMW in a group of patients with severe symptomatic aortic stenosis (AS).</span></span></span></p> <p style="margin-right:-38px; text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:10.0pt">Methods: </span></strong><span style="font-size:10.0pt">we prospectively studied 104 consecutive patients (age: 71 years </span><span style="font-size:10.0pt"><span style="font-family:Symbol">[</span></span><span style="font-size:10.0pt">IQR 66.5-75.5</span><span style="font-size:10.0pt"><span style="font-family:Symbol">]</span></span><span style="font-size:10.0pt"> years, 51% men) with severe symptomatic high gradient AS: mean transaortic pressure gradient: 56.5mmHg </span><span style="font-size:10.0pt"><span style="font-family:Symbol">[</span></span><span style="font-size:10.0pt">IQR 46.8-67.8</span><span style="font-size:10.0pt"><span style="font-family:Symbol">]</span></span><span style="font-size:10.0pt">; aortic valve area: 0.73cm2 </span><span style="font-size:10.0pt"><span style="font-family:Symbol">[</span></span><span style="font-size:10.0pt">IQR 0.61-0.88</span><span style="font-size:10.0pt"><span style="font-family:Symbol">]</span></span><span style="font-size:10.0pt">; indexed stroke volume: 47.7 </span><span style="font-size:10.0pt"><span style="font-family:Symbol">±</span></span><span style="font-size:10.0pt">1.3 mL/m2 (11 patients with low-flow AS), preserved LV ejection fraction (EV) (LVEF: 56.0% [51.0-61.3]; GLS: -14.5% </span><span style="font-size:10.0pt"><span style="font-family:Symbol">[</span></span><span style="font-size:10.0pt">IQR -16.1- -10.6</span><span style="font-size:10.0pt"><span style="font-family:Symbol">]</span></span><span style="font-size:10.0pt">), with no previous coronary artery disease and no history of cardiomyopathy. Beyond complete transthoracic echocardiography, all patients underwent cardiac magnetic resonance for LV myocardium tissue characterization. As proposed for AS, LV systolic pressure was corrected adding the mean transaortic pressure gradient to non-invasive systolic blood pressure cuff measurement in the echocardiographic algorithm. Four LVMW indices were collected in 83 patients (patients excluded for atrial fibrillation, left bundle branch block or absence of non-invasive blood pressure registration) and correlated to LV function indexes, LV hypertrophy and remodeling, myocardial tissue characterization, BNP and troponin levels (<em><span style="color:black">Pearson</span></em><span style="color:black"> or <em>Spearman</em> </span>correlation). These same indexes were compared in patients with LV ejection fraction (EF) below and above 50%, normal and reduced flow and presence of replacement fibrosis. </span></span></span></p> <p style="margin-right:-38px; text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:10.0pt">Results: </span></strong><span style="font-size:10.0pt"><span style="color:black">Global constructive work (GCW) (2658.6 </span></span><span style="font-size:10.0pt"><span style="color:black">±76.4mmHg%),</span></span><span style="font-size:10.0pt"><span style="color:black"> global myocardial work (GMW) (2218.7 </span></span><span style="font-size:10.0pt"><span style="color:black">± 74.9mmHg%) and global wasted work (GWE) (262.0mmHg% </span></span><span style="font-size:10.0pt"><span style="font-family:Symbol"><span style="color:black">[</span></span></span><span style="font-size:10.0pt"><span style="color:black">198.8-339.5</span></span><span style="font-size:10.0pt"><span style="font-family:Symbol"><span style="color:black">]</span></span></span><span style="font-size:10.0pt"><span style="color:black">) were high above normal with concomitant lower work efficiency (WE) (88.0% </span></span><span style="font-size:10.0pt"><span style="font-family:Symbol"><span style="color:black">[</span></span></span><span style="font-size:10.0pt"><span style="color:black">83.2-91.8</span></span><span style="font-size:10.0pt"><span style="font-family:Symbol"><span style="color:black">]</span></span></span><span style="font-size:10.0pt"><span style="color:black">. </span></span><span style="font-size:10.0pt"><span style="color:black">Weak correlations were found between LVMW indexes and parameters describing aortic valve severity, flow and LV function (table). Except for significant differences of LVMI in patients with reduced LV ejection fraction (GCW 2770.3±687.4 vs 2056.0± 380.7mmHg%, p=0,014 and GMW 2362.5 ±657.9 vs 1621.3 ± 319.9, p=0,021 in patients with LV EF>50% vs. LV EF<50%, respectively) work indexes were neither significantly different in low-flow patients nor in those with myocardial late gadolinium enhancement.</span></span></span></span></p> <p style="margin-right:-38px; text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:10.0pt"><span style="color:black">Conclusions: </span></span></strong><span style="font-size:10.0pt"><span style="color:black">Global constructive and myocardial work are increased in these patients with severe aortic stenosis. This might reflect an increased afterload predominance rather than a LV functional impairment, particularly relevant in this group of patients with exclusive high gradient disease and preserved LVEF.</span></span></span></span></p>
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