Usefulness of Electrocardiographic Strain to Predict Survival After Surgical Aortic Valve Replacement for Aortic Stenosis

https://doi.org/10.1016/j.amjcard.2017.06.072Get rights and content

Electrocardiographic (ECG) strain has been reported as a specific marker of midwall left ventricular (LV) myocardial fibrosis, predictive of adverse clinical outcomes in aortic stenosis (AS), but its prognostic impact after aortic valve replacement (AVR) is unknown. We aimed to assess the impact of ECG strain on long-term mortality after surgical AVR for AS. From January 2005 to January 2014, patients with interpretable preoperative ECG who underwent isolated AVR for AS were included. ECG strain was defined as ≥1-mm concave downslopping ST-segment depression with asymmetrical T-wave inversion in lateral leads. Mortality was assessed over a follow-up period of 4.8 ± 2.7 years. Among the 390 patients included, 110 had ECG strain (28%). They had significantly lower body mass index, higher mean transaortic pressure gradient and Cornell-product ECG LV hypertrophy than in those without ECG strain. There was also a trend for lower LV ejection fraction in patients with ECG strain as compared with those without. Patients with ECG strain had significantly lower 8-year survival than those without. ECG strain remained associated with reduced survival both in patients with and without LV hypertrophy (p <0.0001 for both). After adjustment, ECG strain remained a strong and independent determinant of long-term survival (hazard ratio 4.4, p <0.0001). Similar results were found in patients with LV hypertrophy or without LV hypertrophy. In the multivariate model, the addition of ECG strain provided incremental prognostic value (p <0.0001). In conclusion, in patients with AS, ECG strain is associated with 4-fold increased risk of long-term mortality after isolated AVR, regardless of preoperative LV hypertrophy.

Section snippets

Methods

From January 2005 to January 2014, 575 consecutive patients with severe AS underwent isolated SAVR (i.e., without concomitant other valve intervention or coronary artery bypass graft) in our institution. Severe AS was defined as aortic valve area ≤1 cm2 or indexed aortic valve area ≤0.6 cm2/m2 and/or mean transaortic pressure gradient >40 mmHg. All patients with other concomitant significant valve disease (i.e., ≥grade 2 mitral regurgitation, or ≥grade 2 aortic regurgitation, or any mitral

Results

Among the 575 patients who underwent SAVR, included during the period, 390 were selected for the present study (Figure 2), among whom 110 (28%) had ECG strain. The baseline preoperative characteristics of the population are reported in Table 1. Only 11% of patients had reduced (i.e., <50%) LV ejection fraction.

The comparison between patients with ECG strain and those without ECG strain is reported in Table 1. Patients with ECG strain had significantly larger body mass index, higher creatinine

Discussion

The main findings of this study are that in patients with severe AS requiring SAVR, ECG strain (1) is frequent (28%), even in absence of LV hypertrophy (22%); (2) is associated with more severe AS advanced New York Heart Association functional class and low body mass index; and (3) is an independent marker of markedly reduced long-term survival rate, regardless of concomitant LV hypertrophy.

ECG strain is a well-known and validated electrical LV hypertrophy parameter6, 7, 8, 9 associated with

Disclosure

The authors have no conflicts of interest to disclose.

References (23)

Cited by (9)

  • Electrocardiographic left ventricular strain pattern, ST-segment depression and atrial fibrillation at the time of diagnosis of systemic light chain amyloidosis: Incidence and clinical significance

    2021, Journal of Electrocardiology
    Citation Excerpt :

    Myocardial interstitial fibrosis was also observed to be more outspread in patients with ECG strain in comparison to those without [7]. In severe aortic stenosis ECG strain pattern may be present without anatomic LVH [27]. Among 30 ECGs with ST-segment depression high-rate (>100 beats per minute) rhythm was observed in 1 ECG, whereas all other ECGs with ST-segment depression showed normosystolic sinus rhythm or normosystolic AF.

  • The electrocardiogram: Still a useful marker for LV fibrosis in aortic stenosis

    2021, Journal of Electrocardiology
    Citation Excerpt :

    LV strain is independent of LV mass or LVH [7,8,15,31] but is associated with LGE and diffuse interstitial fibrosis by T1 mapping [31], and abnormal GLS and integrated backscatter (IBS) as systolic deformation markers on 2D speckle-tracking echocardiography [32]. The prevalence of ECG strain is 14 to 19% [7,9,15,31] in unselected patients with AS and 21–39% in patients with severe AS [9,12,33]. The prevalence depends on age [12], peak aortic jet velocity [8] and symptoms, and is higher with a reduced LVEF [9,29] and in males [12].

  • Clinical significance of electrocardiographic markers of myocardial damage prior to aortic valve replacement

    2020, International Journal of Cardiology
    Citation Excerpt :

    Moreover, in line with studies identifying GLS and IBS as tools to detect increased myocardial fibrosis [17,23], these 2 parameters exploring the LV were significantly depressed in AS patients with BBB or ECG strain pattern. In addition of being a marker of a more advanced disease, ECG strain was independently associated with poor outcomes, corroborating recent findings by Magne et al. [13]. Based on our findings, multiparametric stratification of patients with severe AS prior to AVR should integrate hallmarks of ventricular myocardial damage.

  • Prognostic Implication of Electrocardiographic Left Ventricular Strain in Patients Who Underwent Transcatheter Aortic Valve Implantation

    2018, American Journal of Cardiology
    Citation Excerpt :

    To our knowledge, this is the first study to document a predicative utility for LV strain specifically in the TAVI population. In a similar study in patients with AS who underwent surgical aortic valve replacement, Guinot et al revealed that patients with ECG strain had 3.3- to 4.4-fold increase in mortality than those without ECG strain despite full adjustment for age, gender, EuroScore-II, and LV hypertrophy.2 In their study, ECG strain provided an incremental predictive value in subgroups of patients with or without LV-hypertrophy (HR 5.66, 95% CI [1.86 to 17.25], p = 0.002; HR 9.10, 95% CI [3.12 to 26.55], p <0.0001, respectively).

View all citing articles on Scopus

Funding Sources: None.

See page 1364 for disclosure information.

1

Equal contribution as first authors.

View full text