*Clinical Applications of Strain Imaging in Aortic Valve Disease DOI: http://dx.doi.org/10.5772/intechopen.93341*

*Advances in Complex Valvular Disease*

LVEF.

• Kafa et al. [37] evaluated 208 patients that underwent AVR for severe AS, measuring GLS pre and 12–24 months post AVR and found that in patients with severe aortic stenosis, approximately 20% of patients who survived more than 1 year after aortic valve replacement had an abnormal LV-GLS value on postoperative echocardiography, despite a preserved postoperative LVEF and demonstrable left ventricular mass regression. This finding was independently associated with adverse events, concluding that appropriately timed aortic valve replacement relieves left ventricular wall stress and prevents a decline in

• In asymptomatic/minimally symptomatic patients with severe bioprosthetic AS undergoing redo aortic valve replacement (AVR), baseline LV-GLS provides incremental prognostic value over established predictors and could potentially

• AVR reverses LA abnormalities and regains normal atrial function, a behavior which is directly related to the severity of preoperative LV outflow tract obstruction. Early identification of LA size enlargement and functional disturbances might contribute to better patient's recruitment for AVR [39].

• Speckle echocardiography analysis of left atrial (LA) myocardial deformation is considered a promising tool for the evaluation of LA subclinical dysfunction in patients undergoing AVR, giving a potentially better risk stratification for

• Gelsomino et al. [41] explored the influence of global longitudinal strain measured with two-dimensional speckle-tracking echocardiography on left ventricular mass regression (LVMR) in 83 patients with pure aortic stenosis (AS) and normal left ventricular function undergoing aortic valve replacement (AVR) and found that global longitudinal strain accurately predicts LV mass

In summary LV GLS can detect subclinical myocardial dysfunction in patients with severe aortic stenosis, and progressively worsens with increasing aortic stenosis severity. Impaired LV GLS is independently associated with increased mortality in high-gradient aortic stenosis, in low-flow, low-gradient severe aortic stenosis with preserved LVEF, and in low-flow, low-gradient severe aortic stenosis with reduced LVEF. Strain analysis of specific myocardial sublayers may add value to the evaluation of strain in aortic stenosis. Coronary artery disease and hypertension produce additional variables in strain analysis that need to be considered. Finally, there is increasing support for the use of strain imaging to determine the need and timing for aortic valve surgery or intervention in patients with aortic stenosis.

In contrast to aortic stenosis, aortic regurgitation (AR) generates LV volume overload with progressive LV dilatation, initially with preservation of LVEF and wall thickness (eccentric LV hypertrophy), but eventually with the development of LV systolic dysfunction expressed by a drop in LVEF (**Figure 2**). Several studies have described the value of strain imaging in the management of patients with aortic regurgitation. The results and conclusion statement of these studies are

aid in surgical timing and risk stratification [38].

the occurrence of postoperative atrial fibrillation [40].

regression in patients with pure AS undergoing AVR.

**12. Strain imaging in aortic regurgitation**

summarized in the following paragraphs:

**50**


### **Figure 2.**

*Severe aortic regurgitation: this patient had severe aortic regurgitation with normal LV end-diastolic and end-systolic volumes (EDV, ESV) and preserved systolic function as estimated by a normal LV ejection fraction (EF) of 68%; however, there is already evidence of insipient LV dysfunction as demonstrated by a mild drop in global longitudinal strain at −14%.*

can discriminate young asymptomatic patients with progressive AR. This could allow young patients with AR to have a better definition of surgical timing before the occurrence of irreversible myocardial damage.


In summary, in patients with severe AR LV strain analysis detects early subclinical myocardial. Dysfunction before there is a drop in LVEF. This provides the potential for improving AVR/intervention timing. In addition GLS may be a useful predictor of mortality in AR patients by providing incremental prognostic value and improved reclassification. Finally, persistently impaired LVGLS in AR is associated with increased mortality.
