**13. Strain imaging in mixed aortic valve disease**

Very little information has been published on the use of strain imaging in the management of patients with mixed aortic valve disease (**Figure 3**). The next paragraph summarizes the findings and conclusions in one study:

• Longitudinal LV function is reduced in both pressure and volume overload, and both of this overload patterns are equally harmful to the ventricle. Gorgulu et al. [49] evaluated a total of 27 subjects with mixed aortic valve disease

**53**

*Clinical Applications of Strain Imaging in Aortic Valve Disease*

(53 ± 15 years). Fifteen healthy subjects (mean age 50 ± 6 years) were enrolled as the control group. Longitudinal peak systolic strain rate values of each segment derived from analysis of a total of 804 segments were significantly decreased in this patient population (P < 0.001). Global longitudinal peak systolic strain rate was also significantly decreased in aortic stenosis and regurgitation compared to the control group (−1 ± 0.5, −0.9 ± 0.3, and −1.6 ± 0.3, P = 0.001). As far as the comparison between patients with aortic stenosis and aortic regurgitation, neither global strain rate nor strain rate for each

*Severe aortic stenosis and regurgitation: this example illustrates the presence of severe LV dysfunction as demonstrated by a marked drop of GLS to −6% despite a borderline drop of LV ejection fraction to 50%. The combination of severe aortic stenosis and regurgitation likely produces significant volume and pressure overload* 

Although strain analysis is been used with increasing frequency for the evaluation of cardiac function, there are still issues with reproducibility of deformation analysis data, particularly when different echocardiography machines or analysis software is used. Until this issue is resolved the current recommendation is to use

The fidelity of the strain data sets is dependent on the quality of the echocardiographic data, unfortunately endocardial contrast enhancing agents cannot be used during strain analysis, therefore strain analysis sometimes has to be obtained with substandard images. The current recommendation is not to report strain values if the echocardiographic images are of poor quality. Hopefully work-around solutions will be found to permit strain analysis with endocardial enhancement agents use. The current literature supports actionable interventions according to fairly welldefined values of decreased LV ejection fraction, this is not as developed on the characterization of LV dysfunction according to levels of decreased strain values.

the same machine and software when obtaining comparative studies.

myocardial segment was found to be different.

*of the LV with significant LV dysfunction that is unmasked by strain analysis.*

**14. Unresolved issues**

**Figure 3.**

*DOI: http://dx.doi.org/10.5772/intechopen.93341*

**Figure 3.**

*Advances in Complex Valvular Disease*

can discriminate young asymptomatic patients with progressive AR. This could allow young patients with AR to have a better definition of surgical timing

correction and found, with the use of speckle-tracking strain imaging, that LV subendocardial dysfunction was present in patients with chronic severe AR

• Kaneko et al. [45] evaluated 36 chronic AR patients undergoing surgical

• Park et al. [46] evaluated 60 patients with chronic AR with LV global strain rate on apical four chamber image (GS-4CH). During 64 months follow-up duration, 16 patients (26.7%) were deceased and 38 patients (63.3%) underwent aortic valve replacement (AVR). Deceased group had lower longitudinal strain (−12.05 ± 3.72% vs. -15.66 ± 4.35%, p = 0.005). On multivariate analysis by cox proportional hazard model adjusting for age, sex, body surface area, history of atrial fibrillation, blood urea nitrogen, LV dilatation, LV ejection fraction and AVR, decreased GS-4CH proved to be an independent predictor of mortality in patients with chronic AR (hazard ratio 1.313, 95% confidence interval 1.010–1.706, p = 0.042). They concluded that GS-4CH may be a useful

• Alashi et al. [47] evaluated 1063 patients with asymptomatic severe chronic AR and preserved LVEF to examine the prognostic utility of left ventricular (LV) global longitudinal strain (GLS). A significantly higher proportion (log-rank p = 0.01) of patients with LV-GLS worse than median (−19.5%) died versus those with an LV-GLS better than median [86 of 513 (17%) vs. 60 of 550 (11%)]. The risk of death at 5 years significantly increased with an LV-GLS of worse than −19%. They concluded that in asymptomatic patients with ≥III+ chronic AR and preserved LVEF, worsening LV-GLS was associated with longer term mortality,

providing incremental prognostic value and improved reclassification.

• Alashi et al. [48] evaluated 865 patients with ≥3+ chronic AR and preserved LVEF undergoing AV surgery, a baseline LV-GLS value worse than −19% was associated with reduced survival. In a subgroup of patients who returned for 3- and 12-month postoperative follow-up examinations, persistently impaired

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 associ-

Very little information has been published on the use of strain imaging in the management of patients with mixed aortic valve disease (**Figure 3**). The next

• Longitudinal LV function is reduced in both pressure and volume overload, and both of this overload patterns are equally harmful to the ventricle. Gorgulu et al. [49] evaluated a total of 27 subjects with mixed aortic valve disease

before the occurrence of irreversible myocardial damage.

and preserved EF, this improved after surgical correction.

predictor of mortality in patient with chronic AR.

LV-GLS was associated with increased mortality.

**13. Strain imaging in mixed aortic valve disease**

paragraph summarizes the findings and conclusions in one study:

ated with increased mortality.

**52**

*Severe aortic stenosis and regurgitation: this example illustrates the presence of severe LV dysfunction as demonstrated by a marked drop of GLS to −6% despite a borderline drop of LV ejection fraction to 50%. The combination of severe aortic stenosis and regurgitation likely produces significant volume and pressure overload of the LV with significant LV dysfunction that is unmasked by strain analysis.*

(53 ± 15 years). Fifteen healthy subjects (mean age 50 ± 6 years) were enrolled as the control group. Longitudinal peak systolic strain rate values of each segment derived from analysis of a total of 804 segments were significantly decreased in this patient population (P < 0.001). Global longitudinal peak systolic strain rate was also significantly decreased in aortic stenosis and regurgitation compared to the control group (−1 ± 0.5, −0.9 ± 0.3, and −1.6 ± 0.3, P = 0.001). As far as the comparison between patients with aortic stenosis and aortic regurgitation, neither global strain rate nor strain rate for each myocardial segment was found to be different.
