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Assessment of left ventricular function in aortic stenosis

Nature Reviews Cardiology volume 8, pages 494–501 (2011)Cite this article

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Abstract

Degenerative aortic stenosis (AS) has become the most common valvular heart disease and the definitive treatment of symptomatic, severe AS is surgical valve replacement. In the absence of symptoms, the presence of left ventricular (LV) systolic dysfunction is pivotal in making treatment decisions for patients with AS. However, the LV ejection fraction is not a sensitive marker of global LV systolic function in the presence of LV hypertrophy, implying that asymptomatic patients with AS can have myocardial dysfunction with preserved LV ejection fraction. Abnormal myocardial mechanics might explain the pathophysiological processes underlying chronic pressure overload in AS. In this article, we review how new echocardiographic deformation parameters—such as myocardial strain, strain rate, and twist measurements—offer the potential for clinicians to monitor the course of LV dysfunction in patients with AS. Quantifying disturbances in LV function might provide insight into the timing of aortic valve replacement and into the improvement of LV systolic and diastolic properties through regression of LV hypertrophy and fibrosis after valve implantation.

Key Points

  • Assessment of left ventricular (LV) function has a pivotal role in clinical decision making for patients with severe aortic stenosis, particularly if they are asymptomatic

  • Conventional echocardiography indices such as LV ejection fraction, LV volumes, and fractional shortening are load-dependent and are not sensitive markers of global LV systolic function, especially in the setting of LV hypertrophy

  • Assessment of myocardial deformation parameters can provide better quantitation of regional and global systolic function, and might have increased sensitivity in detecting subtle myocardial dysfunction

  • Combining myocardial deformation parameters with conventional echocardiographic measurements might be useful for determining the timing of aortic valve replacement or for monitoring the improvement of LV systolic and diastolic properties after valve replacement

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Figure 1: Left ventricular responses to aortic stenosis.
Figure 2: Multidimensional strain measurement analysis in a healthy individual.
Figure 3: Echocardiographic changes, including deformation parameters, in a patient with severe aortic stenosis before and after successful AVR.
Figure 4: Echocardiographic assessment of LV rotation in a healthy individual.

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Author information

Authors and Affiliations

  1. Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Mail Code J1-5, Cleveland, 44195, Ohio, USA

    Alper Ozkan, Samir Kapadia, Murat Tuzcu & Thomas H. Marwick

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  1. Alper Ozkan
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  2. Samir Kapadia
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All authors contributed equally to the research of data and the writing of the article, provided substantial contributions to the discussion of content, and reviewed and/or edited the manuscript before submission.

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Correspondence to Thomas H. Marwick.

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Supplementary information

Supplementary Figures

Supplementary Figures 1–3 (PDF 738 kb)

Supplementary Video 1

Left-ventricular longitudinal strain analysis using transthoracic, two-dimensional speckle tracking echocardiography. The video shows an apical four chamber view of the heart during one cardiac cycle of a patient with aortic stenosis before aortic valve replacement. Segments of the myocardial wall are marked by dotted lines for segmental strain analysis. Red indicates myocardial shortening and blue indicates lengthening. In this patient, global left-ventricular longitudinal strain was quantified as 8.2%. See Supplementary Figure 1 for details on data analysis. (MOV 392 kb)

Supplementary Video 2

This video shows transthoracic, two-dimensional speckle tracking echocardiography performed 6 months after aortic valve replacement on the same patient as in Supplementary Video 1. Global left-ventricular longitudinal strain improved to 14%. Note the more dynamic contraction compared with the heart before aortic valve surgery. See Supplementary Figure 2 for details on data analysis. (MOV 299 kb)

Supplementary Video 3

Parasternal short axis view from the apical level of the left ventricle. Apical rotation of the heart is visualized by transthoracic echocardiography. Note the counterclockwise rotation throughout systole. (MOV 203 kb)

Supplementary Video 4

Rotational motion of the heart apex. Two-dimensional speckle tracking software was applied to Supplementary Video 3 for quantification of deformation parameters. Segments of the myocardial wall are highlighted by dotted lines. The color-coded image demonstrates systolic counterclockwise rotation (blue) and clockwise diastolic rotation (red). See also Supplementary Figure 3a. (MOV 299 kb)

Supplementary Video 5

Parasternal short axis view of left ventricle at the level of the mitral valve as seen by transthoracic echocardiography. Note the clockwise rotation of the left ventricle during systole. (MOV 171 kb)

Supplementary Video 6

Rotational motion of the heart at the level of the mitral valve. Two-dimensional speckle tracking software was applied to Supplementary Video 5. Segments of the myocardial wall are highlighted by dotted lines. The color-coded image demonstrates diastolic counterclockwise rotation (blue) and systolic clockwise rotation (red). See also Supplementary Figure 3b. (MOV 414 kb)

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Ozkan, A., Kapadia, S., Tuzcu, M. et al. Assessment of left ventricular function in aortic stenosis. Nat Rev Cardiol 8, 494–501 (2011). https://doi.org/10.1038/nrcardio.2011.80

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