Key result
Severe aortic regurgitation without surgical indication exhibits ~38% lower LV contractility versus controls.
Why the study?
Recent mortality studies showed worse prognosis in patients with severe aortic regurgitation and preserved EF not meeting current surgical guidelines, prompting evaluation of LV function and mechanical energetics.
Do patients with severe aortic regurgitation without indication for surgery have impaired LV contractility and energetics compared to controls?
Observational (n=80)
Do patients with severe aortic regurgitation without indication for surgery have impaired LV contractility and energetics compared to controls?
Patients with severe aortic regurgitation not meeting current surgical criteria already exhibit significant hemodynamic and energetic deterioration, suggesting global longitudinal strain may be a better marker for timing surgery.
OBJECTIVES: Recent mortality studies showed worse prognosis in patients (ARNS) with severe aortic regurgitation and preserved ejection fraction (EF) not fulfilling the criteria of current guidelines for surgery. The aim of our study was to analyse left ventricular (LV) systolic and diastolic function and mechanical energetics to find haemodynamic explanations for the reduced prognosis of these patients and to seek a new concept for surgery. METHODS: Global longitudinal strain (GLS) and echo-based single-beat pressure-volume analyses were performed in patients with ARNS (LV end-diastolic diameter <70 mm, EF >50%, GLS > -19% n = 41), with indication for surgery (ARS; n = 19) and in mild hypertensive controls (C; n = 20). Additionally, end-systolic elastance (LV contractility), stroke work and total energy (pressure-volume area) were calculated. RESULTS: ARNS demonstrated significantly depressed LV contractility versus C: end-systolic elastance (1.58 ± 0.7 vs 2.54 ± 0.8 mmHg/ml; P < 0.001), despite identical EF (EF: 59 ± 6% vs 59 ± 7%). Accordingly, GLS was decreased [-15.7 ± 2.7% (n = 31) vs -21.2 ± 2.4%; P < 0.001], end-diastolic volume (236 ± 90 vs 136 ± 30 ml; P < 0.001) and diastolic operant stiffness were markedly enlarged, as were pressure-volume area and stroke work, indicating waste of energy. The correlation of GLS versus end-systolic elastance was good (r = -0.66; P < 0.001). ARNS and ARS patients demonstrated similar haemodynamic disorders, whereas only GLS was worse in ARS. CONCLUSIONS: ARNS patients almost matched the ARS patients in their haemodynamic and energetic deterioration, thereby explaining poor prognosis reported in literature. GLS has been shown to be a reliable surrogate for LV contractility, possibly overestimating contractility due to exhausted preload reserve in aortic regurgitation patients. GLS may outperform conventional echo parameters to predict more precisely the timing of surgery.
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Reil et al. (2020) conducted an observational in Severe aortic regurgitation (n=80). Severe aortic regurgitation without indication for surgery vs. Mild hypertensive controls and patients with indication for surgery was evaluated on End-systolic elastance (LV contractility) (p=<0.001). Severe aortic regurgitation patients without surgical indication had significantly depressed LV contractility versus controls (end-systolic elastance 1.58 vs 2.54 mmHg/ml; P<0.001).
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