**16.4 Diastolic strain**

*Advances in Complex Valvular Disease*

aortic valve disease.

**disease**

intervention.

**16. Future directions**

patients.

these patients [51].

**16.3 Multi-layer strain**

stenosis [23].

**16.2 Stress GLS**

**16.1 Three-dimensional speckle tracking**

Although the literature on strain is fairly robust in aortic stenosis, it is only moderately developed in aortic regurgitation and almost not existent in mixed

**15. Incorporating strain analysis into clinical practice in aortic valve** 

Despite some of the shortcomings of strain analysis in aortic valve disease we have reviewed, we feel the added value this technique provides, justifies its use in the day to day imaging management of patients with diseases of the aortic valve. Our practice and recommendation is to characterize and sequentially follow global longitudinal strain in patients with moderate and severe aortic stenosis and/or moderate and severe aortic regurgitation. In asymptomatic patients with severe AS or AR and normal EF, the presence of an abnormal GLS should alert the clinician for the need of closer follow up or possibly aortic valve replacement/

The following studies highlight areas of study with high potential for develop-

• Broch et al. [50] studied, 31 patients with moderate to severe AR, 15 elite endurance athletes, and 17 healthy control subjects using three-dimensional speckle-tracking echocardiography. Global circumferential strain (GCS), global longitudinal strain (GLS), end-systolic circumferential wall stress (ESSc), end-systolic meridional wall stress (ESSm), and the wall stress ratio (ESSc/ESSm) were measured. LV end-diastolic volumes were similar in athletes and patients with AR and significantly larger than in healthy control subjects. Values of GLS in control subjects, athletes, and patients with AR were −18.8 ± 1.9%, −17.3 ± 2.0%, and −16.4± 2.0%, respectively (control subjects vs. athletes and patients, P < .05), whereas values of GCS were −16.9 ± 2.0%, −15.5 ± 1.9%, and −17.9 ± 2.6%, respectively (athletes vs. control subjects and patients, P < .01). The authors concluded that in compensated AR, relatively high GCS compensates for reduced GLS in a manner consistent with the preserved ejection fractions observed in these

• Uncovering post-exercise myocardial dysfunction in patients with asymptomatic AS with preserved left ventricular function can aid in risk assessment of

• Left ventricular myocardial strain gradient using a novel multi-layer transthoracic echocardiography technique positively correlates with severity of aortic

ment in the area of strain analysis in patients with aortic valve disease.

**54**

• Early diastolic strain rate in relation to systolic and diastolic function and prognosis in aortic stenosis [52].
