Vol 22, No 6 (2015)
Original articles
Published online: 2015-06-19

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Severe aortic stenosis with preserved ejection fraction and evidence of impairment in structure, myocardial strain and ventricular function: A new contribution to clinical decision making

Alejandro Hita, Sergio Baratta, Guillermo Vaccarino, José Navia, Daniel Olano, Juan Manuel Telayna, Ricardo Costantini, Demian Chejtman, Miriam Matoso, Ricardo J. Gelpi, Martin Donato, Celina Morales
DOI: 10.5603/CJ.a2015.0034
Pubmed: 26100828
Cardiol J 2015;22(6):613-621.

Abstract

Background: Left ventricular ejection fraction (LVEF) is among the parameters that are usually employed to define surgical timing of severe aortic stenosis (AS). Our hypothesis states that even when their LVEF is preserved, patients with severe symptomatic AS have impaired myocardial structure and function, and such impairment is related to the deleterious progression of left ventricular hypertrophy (LVH) from the compensated to the decompensated stage, as shown by the changes in diastolic function and the increase in left ventricular end-diastolic pressure (LVEDP).

Methods and Results: A total of 26 patients with severe AS and LVEF > 50% referred for aortic valve replacement underwent catheterization, echocardiography and an intraoperative biopsy. Patients with severe symptomatic AS were classified as: group 1 (G1; compensated LVH, LVEDP < 15 mm Hg without coronary artery disease [CAD], n = 7), group 2a (G2a, decom­pensated LVH, without CAD, n = 7), and group 2b (G2b, decompensated LVH with CAD, n = 12). Differences were seen in the following: myocyte area [μm2]: G1: 328 ± 66, G2a: 376 ± 22, G2b: 385 ± 13, p < 0.01; collagen volume [%]: G1: 4.77 ± 1.27, G2a: 8.40 ± 1.27, G2b: 11.05 ± 3.08, p < 0.01; LVEDP normalized by diastolic diameter [mm Hg/mm]: G1: 0.27 ± 0.01, G2a: 0.39 ± 0.06, G2b: 0.44 ± 0.11, p < 0.02; +dP/dtmax/LVEDP [mm Hg/s/mm Hg]: G1: 176 ± 45, G2a: 89.6 ± 20, G2b: 113.1 ± 41, p < 0.01; two-dimensional peak systolic longitudinal strain [%]: G1: –17.7 ± 4.75, G2a: –13.4 ± 3.04, G2b: –13.5 ± 3.13, p < 0.05.

Conclusions: Patients with severe symptomatic AS and preserved ejection fraction who de­velop decompensated LVH characterized by increased LVEDP, exhibit an abnormal myocardial structure and diastolic and systolic impairment.