Area strain from 3D speckle-tracking echocardiography as an independent predictor of early symptoms or ventricular dysfunction in asymptomatic severe mitral regurgitation with preserved ejection fraction

  • Eduardo Casas-Rojo
  • Covadonga Fernández-Golfin
  • José Luis Moya-Mur
  • Ariana González-Gómez
  • Ana García-Martín
  • Laura Morán-Fernández
  • Daniel Rodríguez-Muñoz
  • José Julio Jiménez-Nacher
  • David Martí Sánchez
  • José Luis Zamorano Gómez
Original Paper

Abstract

The indication for surgery in asymptomatic severe mitral regurgitation (SMR) with preserved left ventricular ejection fraction (LVEF) is controversial. We sought to study 3D myocardial mechanics in this population and test 3D-speckle tracking (3DST) parameters as possible predictors of events. 45 asymptomatic patients with SMR and LVEF >60 % and 20 control individuals without cardiac disease underwent 3DST echocardiography. MR group additionally underwent further clinical monitoring. Dyspnea, LVEF under 60 %, or admissions for heart failure were considered as events. When compared with control group, MR group showed lower percentage of global 3D strain, (35.4 ± 9.1 vs. 43.9 ± 10.6; p = 0.003), lower radial strain, lower area change rate and higher end-diastolic volume. In a follow-up time of 23.2 ± 14.5 months we found 15 events (33.3 %). When comparing the remaining patients with this new-onset HF group we found significant differences in longitudinal strain (−17.9 ± 3.3 vs. −15.8 ± 2.1; p = 0.036), area strain (AS) (−48.6 ± 4.6 vs. −43.7 ± 6.2; p = 0.006), circumferential strain (−35.8 ± 4.7 vs. −31.8 ± 6.1; p = 0.034), 3D LVEF (67.1 ± 4.6 vs. 63.0 ± 7.4; p = 0.034) and E/E′ index (13.5 ± 3.9 vs. 19.3 ± 9.5; p = 0.006). In multivariate Cox regression AS alone was the only independent predictor. A cutoff value of AS greater than −41.6 % reached a hazard ratio of 4.41 (p = 0.004) for prediction of events. In asymptomatic patients with SMR and preserved ejection fraction, 3DST derived AS is a promising tool for predicting the development of heart failure. This finding may be useful for guiding the selection of patients for early mitral valve repair/replacement surgery even if they are asymptomatic.

Keywords

3D speckle-tracking Mitral regurgitation Area strain Cardiac mechanics Heart failure Echocardiography 

Notes

Acknowledgments

All the authors declare that the paper is not under consideration elsewhere; none of the paper’s contents have been previously published; all authors have read and approved the manuscript.

Funding

There was no external funding.

Compliance with ethical standards

Conflict of interest

No conflicts of interest exist. No relationships with the industry are declared.

References

  1. 1.
    Ling LH, Enriquez-Sarano M, Seward JB, Tajik AJ, Schaff HV, Bailey KR et al (1996) Clinical outcome of mitral regurgitation due to flail leaflet. N Engl J Med 335:1417–1423CrossRefPubMedGoogle Scholar
  2. 2.
    Avierinos JF, Gersh BJ, Melton LJ 3rd, Bailey KR, Shub C, Nishimura RA et al (2002) Natural history of asymptomatic mitral valve prolapse in the community. Circulation 106(11):1355–1361CrossRefPubMedGoogle Scholar
  3. 3.
    Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V et al (2005) Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 352:875–883CrossRefPubMedGoogle Scholar
  4. 4.
    Rosenhek R, Rader F, Klaar U, Gabriel H, Krejc M, Kalbeck D et al (2006) Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation 113:2238–2244CrossRefPubMedGoogle Scholar
  5. 5.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA et al (2014) 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 129:2440–2492Google Scholar
  6. 6.
    Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H et al (2012) Joint Task Force on the Management of Valvular Heart Disease of the ESC, European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 33(19):2451–2496CrossRefPubMedGoogle Scholar
  7. 7.
    Enriquez-Sarano M, Schaff HV, Orszulak TA, Bailey KR, Tajik AJ, Frye RL (1995) Congestive heart failure after surgical correction of mitral regurgitation. a long-term study. Circulation 92:2496–2503CrossRefPubMedGoogle Scholar
  8. 8.
    Grayburn PA, Weissman NJ, Zamorano JL (2012) Quantitation of mitral regurgitation. Circulation 126:2005–2017CrossRefPubMedGoogle Scholar
  9. 9.
    Mor-Avi V, Lang RM, Badano LP, Belohlavek M, Cardim NM, Derumeaux G et al (2011) Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography. Eur J Echocardiogr 12(3):167–205CrossRefPubMedGoogle Scholar
  10. 10.
    Perez de Isla L, de Agustin A, Rodrigo JL, Almeria C, del Carmen Manzano M, Rodríguez E et al (2009) Chronic mitral regurgitation: a pilot study to assess preoperative left ventricular contractile function using speckle-tracking echocardiography. J Am Soc Echocardiogr 22(7):831–838CrossRefGoogle Scholar
  11. 11.
    De Agustín JA, Pérez de Isla L, Núñez-Gil IJ, Vivas D, Manzano Mdel C, Marcos-Alberca P et al (2010) Assessment of myocardial deformation: predicting medium-term left ventricular dysfunction after surgery in patients with chronic mitral regurgitation. Rev Esp Cardiol 63(5):544–553CrossRefPubMedGoogle Scholar
  12. 12.
    Ternacle J, Berry M, Alonso E, Kloeckner M, Couetil JP, Randé JL, Gueret P et al (2013) Incremental value of global longitudinal strain for predicting early outcome after cardiac surgery. Eur Heart J Cardiovasc Imaging 14(1):77–84CrossRefPubMedGoogle Scholar
  13. 13.
    Witkowski TG, Thomas JD, Debonnaire PJ, Delgado V, Hoke U, Ewe SH et al (2013) Global longitudinal strain predicts left ventricular dysfunction after mitral valve repair. Eur Heart J Cardiovasc Imaging 14(1):69–76CrossRefPubMedGoogle Scholar
  14. 14.
    Urbano-Moral JA, Patel AR, Maron MS, Arias-Godinez JA, Pandian NG (2012) Three-dimensional speckle-tracking echocardiography: methodological aspects and clinical potential. Echocardiography 29(8):997–1010CrossRefPubMedGoogle Scholar
  15. 15.
    Ammar KA, Paterick TE, Khandheria BK, Jan MF, Kramer C, Umland MM et al (2012) Myocardial mechanics: understanding and applying three-dimensional speckle tracking echocardiography in clinical practice. Echocardiography 29(7):861–872CrossRefPubMedGoogle Scholar
  16. 16.
    Starling MR, Kirsch MM, Montgomery DG, Gross MD (1993) Impaired left ventricular contractile function in patients with long-term mitral regurgitation and normal ejection fraction. J Am Coll Cardiol 22:239–250CrossRefPubMedGoogle Scholar
  17. 17.
    Kaku K, Takeuchi M, Tsang W, Takigiku K, Yasukochi S, Patel AR, Mor-Avi V et al (2014) Age-related normal range of left ventricular strain and torsion using three-dimensional speckle-tracking echocardiography. J Am Soc Echocardiogr 27(1):55–64CrossRefPubMedGoogle Scholar
  18. 18.
    Badano LP, Cucchini U, Muraru D, Al Nono O, Sarais C, Iliceto S (2013) Use of three-dimensional speckle tracking to assess left ventricular myocardial mechanics: inter-vendor consistency and reproducibility of strain measurements. Eur Heart J Cardiovasc Imaging 14(3):285–293CrossRefPubMedGoogle Scholar
  19. 19.
    Krauss J, Pizarro R, Oberti PF, Falconi M, Cagide A (2006) Prognostic implication of valvular lesion and left ventricular size in asymptomatic patients with chronic organic mitral regurgitation and normal left ventricular performance. Am Heart J 152(5):1004.e1–8CrossRefPubMedGoogle Scholar
  20. 20.
    Magne J, Mahjoub H, Pierard LA, O’Connor K, Pirlet C, Pibarot P et al (2012) Prognostic importance of brain natriuretic peptide and left ventricular longitudinal function in asymptomatic degenerative mitral regurgitation. Heart 98(7):584–591CrossRefPubMedGoogle Scholar
  21. 21.
    Florescu M, Benea DC, Rimbas RC, Cerin G, Diena M, Lanzzillo G et al (2012) Myocardial systolic velocities and deformation assessed by speckle tracking for early detection of left ventricular dysfunction in asymptomatic patients with severe primary mitral regurgitation. Echocardiography 29(3):326–333CrossRefPubMedGoogle Scholar
  22. 22.
    Katz AM (2002) Ernest Henry Starling, his predecessors, and the “Law of the Heart”. Circulation 106:2986–2992CrossRefPubMedGoogle Scholar
  23. 23.
    Nesser HJ, Mor-Avi V, Gorissen W, Weinert L, Steringer-Mascherbauer R, Niel J et al (2009) Quantification of left ventricular volumes using three-dimensional echocardiographic speckle tracking: comparison with MRI. Eur Heart J 30(13):1565–1573CrossRefPubMedGoogle Scholar
  24. 24.
    Saito K, Okura H, Watanab N, Hayashida A, Obase K, Imai K et al (2009) Comprehensive evaluation of left ventricular strain using speckle tracking echocardiography in normal adults: comparison of three-dimensional and two-dimensional approaches. J Am Soc Echocardiogr 22(9):1025–1030CrossRefPubMedGoogle Scholar
  25. 25.
    Yodwut C, Weinert L, Klas B, Lang RM, Mor-Avi V (2012) Effects of frame rate on three-dimensional speckle-tracking-based measurements of myocardial deformation. J Am Soc Echocardiogr 25(9):978–985CrossRefPubMedGoogle Scholar
  26. 26.
    Kleijn SA, Aly MFA, Terwee CB, Van Rossum AC, Kamp O (2012) Reliability of left ventricular volumes and function measurements using three-dimensional speckle tracking echocardiography. Eur Heart J Cardiovasc Imaging 13:159–168CrossRefPubMedGoogle Scholar
  27. 27.
    Perez de Isla L, Millan M, Lennie V, Quezada M, Guinea J, Macaya C, Zamorano J (2011) Area strain: normal values for a new parameter in healthy people. Rev Esp Cardiol 64:1194–1197CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2016

Authors and Affiliations

  • Eduardo Casas-Rojo
    • 1
  • Covadonga Fernández-Golfin
    • 1
  • José Luis Moya-Mur
    • 1
  • Ariana González-Gómez
    • 1
  • Ana García-Martín
    • 1
  • Laura Morán-Fernández
    • 1
  • Daniel Rodríguez-Muñoz
    • 1
  • José Julio Jiménez-Nacher
    • 1
  • David Martí Sánchez
    • 2
  • José Luis Zamorano Gómez
    • 1
  1. 1.Cardiac Imaging Unit, Department of CardiologyRamón y Cajal University HospitalMadridSpain
  2. 2.Hospital Central de la DefensaMadridSpain

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