Shaping the Optimal Timing for Treatment of Isolated Asymptomatic Severe Aortic Stenosis with Preserved Left Ventricular Ejection Fraction: The Role of Non-Invasive Diagnostics Focused on Strain Echocardiography and Future Perspectives

Figures

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  Figure 1. An example of SAS diagnosis by echocardiographic two-dimensional (2D) and Doppler data [9,10]. Two-dimensional parasternal long-axis view showing inner edge to inner edge measurement (2.1 cm) of aortic valve annulus at mid-systole (A); 2D apical five-chamber view with aortic transvalvular aliasing suggesting SAS (B); pulsed-wave (PW) Doppler (maximum velocity measured at 1.00 m/s) (C); and continuous-wave (CW) Doppler (maximum velocity measured at 4.21 m/s; maximum and mean gradients calculated result 70.77 mmHg and 46.22 mmHg, respectively) (D) measured from 2D apical five-chamber view diagnosing SAS.

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  Figure 2. An example of LV function evaluation by LV GLS, in the presence of SAS, assessed from 2D apical four-chamber view (A), three-chamber view (B), two-chamber view (C), and finally reported “bull’s eye” GLS plot (D). Note: the most impaired longitudinal strain results in basal segments (see “bull’s eye” plot in D), showing the typical gradient between basal and apical segments in decreasing longitudinal function [35].

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  Figure 3. An example of LV function evaluation by LV GLS, in the presence of SAS and LV dysfunction, assessed from 2D apical four-chamber, three-chamber, and two-chamber views. When overt LV dysfunction occurs, the mentioned typical gradient between basal and apical segments in decreasing longitudinal function (initially in the presence of preserved LV EF) may finally develop an “apical sparing-like” picture (see “bull’s eye” plot in (A) and the corresponding MW analysis in (B)).

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  Figure 4. An example of LA function evaluation by LA strain technique, in the presence of SAS, assessed from 2D apical four-chamber and two-chamber views. In two asymptomatic patients with relatively similar LV EF (66% and 60%), notably, biplane LA reservoir peak atrial longitudinal strain (PALS) is different: >20% (A) and <20% (B), respectively.

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  Figure 5. LV function evaluation by both GLS (A) and MW (B), in the presence of preserved LV EF and asymptomatic SAS. In this example, the previously mentioned typical gradient between basal and apical segments in decreasing longitudinal function assessed by GLS [35] (A) is more and more evident when evaluated by MW analysis, whose “bull’s eye” plot looks like an “apical sparing” plot (B).