Myocardial Deformation Imaging by Two-Dimensional Speckle-Tracking Echocardiography in Comparison to Late Gadolinium Enhancement Cardiac Magnetic Resonance for Analysis of Myocardial Fibrosis in Severe Aortic Stenosis




Myocardial deformation analysis by speckle-tracking echocardiography (STE) has been used for analysis of myocardial viability and myocardial fibrosis. Patients with severe aortic stenosis are known to develop myocardial fibrosis. This study evaluated the association between myocardial fibrosis determined by late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) and 2-dimensional STE in patients with severe aortic stenosis. In 30 patients (78 ± 7 years) with severe aortic stenosis (mean gradient 53 ± 21 mm Hg), peak systolic circumferential strain based on 2-dimensional echocardiographic parasternal short-axis views and peak systolic longitudinal strain based on apical views were determined for analysis of regional function. LGE CMR was performed to define the amount of fibrosis in each segment within 24 hours of echocardiography. Relative amount of fibrosis was determined based on LGE CMR as gray-scale threshold 6 SDs above the mean signal intensity of the normal remote myocardium. There was a decrease in LGE from base to apex (14.4 ± 8.7% for basal segments, 3.4 ± 3.0% for midventricular segments, and 2.1 ± 3.0% for apical segments; p <0.001). Simultaneously, there was an increase in myocardial deformation expressed as peak systolic longitudinal strain from base to apex (−11.6 ± 7.0% for basal segments, −16.9 ± 6.5% for midventricular segments, and −17.4 ± 7.7% for apical segments; p = 0.001). There was a negative correlation between the amount of myocardial fibrosis determined by LGE CMR and peak systolic longitudinal strain for the total left ventricle (r = −0.538, p = 0.007). Myocardial fibrosis defined as LGE >10% could be identified by peak systolic longitudinal strain less than −11.6%, with a sensitivity of 65% and a specificity of 75% (area under the receiver operating characteristic curve 0.69). In conclusion, myocardial fibrosis increases from apical to basal left ventricular segments in patients with severe aortic stenosis. There is an association between severity of myocardial fibrosis defined by LGE CMR and myocardial deformation by STE.


In patients with aortic stenosis, left ventricular (LV) hypertrophy and interstitial myocardial fibrosis are known sequel of chronic pressure overload. The changes result in gradual impairment of systolic and diastolic function and may result in the typical symptoms of angina pectoris and dyspnea. Typical parameters to evaluate aortic stenosis include hemodynamic parameters such as pressure gradients, aortic valve area, and LV ejection fraction. In contrast, alterations of myocardial texture resulting from aortic stenosis such as myocardial fibrosis are hardly evaluated in clinical practice as there is no imaging tool easily providing information about fibrotic changes. Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) imaging has been described as a tool for reliable analysis of myocardial fibrosis. Speckle-tracking echocardiography (STE) allows accurate analysis of regional myocardial function. It has been found to accurately reflect myocardial viability and extent of necrosis in ischemic cardiomyopathy. There are only little data on the potential of STE to define myocardial function and the degree of myocardial fibrosis in patients with severe aortic stenosis. This study evaluated the extent and distribution of myocardial fibrosis in patients with symptomatic severe aortic stenosis using LGE CMR. Furthermore, findings of LGE CMR were compared with those obtained by 2-dimensional (2D) STE.


Methods


We screened 42 consecutive patients with symptomatic aortic stenosis undergoing cardiac catheterization. Contraindications for LGE CMR such as device therapy or severe renal dysfunction and insufficient echocardiographic windows resulted in exclusion of a patient. Further exclusion criteria were previous myocardial infarction, atrial fibrillation, or significant ventricular arrhythmia. Considering these inclusion and exclusion criteria, 30 patients (age 78 ± 7 years) formed the study group. The patient characteristics are listed in Table 1 .



Table 1

Patient characteristics, late gadolinium enhancement CMR data as well as longitudinal and circumferential myocardial strain data at the basal, midventricular and apical level for each of the 30 patients




























































































































































































































































































































































































































































































































































































































































































































































































































Patient Age Gender NYHA LVEDV LVESV LV-EF CMR Mass Mean Grad Max Grad AVA LE Bas LE Mid LE Apic LE Total Circ Bas Long Bas Circ Mid Long Mid Circ Apic Long Apic Circ Glob Long Glob
1 71 M 2 128 49 62 216 70 88 0.5 10 7 3 8 13.7 7.0 13.8 9.5 18.7 10.2 15.4 8.9
2 75 M 3 142 57 60 190 50 73 0.8 9 2 2 5 24.8 17.2 24.5 17.2 27.7 18.2 25.7 17.5
3 71 M 3 171 88 49 245 36 60 1.1 14 4 2 9 10.0 13.2 9.2 22.3 15.8 23.4 11.7 19.6
4 71 M 4 146 79 46 319 56 77 0.7 28 5 1 11 10.0 6.8 9.6 12.4 20.5 13.1 13.4 11.2
5 70 F 3 138 53 62 197 80 131 0.5 12 2 0 7 23.3 16.0 23.5 23.2 16.6 25.0 21.1 21.4
6 79 F 3 109 49 55 87 51 76 0.6 0 0 0 0 27.0 31.2 27.4 29.8 22.3 35.5 25.6 32.1
7 87 F 3 133 65 51 90 42 58 0.9 0 0 0 0 14.0 16.9 14.3 21.2 16.7 13.0 15.0 19.0
8 89 M 3 89 35 61 139 66 90 0.7 26 0 0 10 21.7 15.0 21.6 31.9 32.2 38.0 25.2 28.3
9 67 M 3 191 82 57 244 68 100 0.8 4 0 0 2 19.6 21.3 15.5 24.2 19.3 25.0 18.1 23.4
10 74 M 3 215 98 54 215 65 100 0.6 16 8 3 10 14.8 6.9 16.1 13.2 15.8 13.1 15.6 11.1
11 89 F 4 85 34 60 92 24 37 1.0 26 7 5 13 12.3 1.0 12.7 16.2 19.4 16.1 14.8 11.1
12 85 F 3 160 66 59 210 87 88 0.5 9 4 2 6 14.6 7.0 14.8 11.8 20.7 12.4 16.7 10.4
13 83 M 3 156 66 58 190 51 85 0.8 1 0 0 0 16.2 12.1 18.0 16.7 11.4 16.9 15.2 15.2
14 82 F 4 184 100 46 265 59 90 0.8 20 7 3 12 17.3 10.2 16.8 17.9 17.2 20.1 17.1 16.0
15 76 F 3 101 42 58 162 56 85 0.8 11 9 13 12 17.1 4.8 17.2 5.9 22.4 6.3 18.9 5.7
16 79 M 3 116 52 55 210 55 80 0.8 10 1 0 4 23.3 19.0 23.6 17.2 20.2 17.3 22.4 17.8
17 72 M 3 160 71 56 254 52 90 0.8 11 2 0 5 9.2 15.1 8.5 11.1 12.7 8.3 10.1 11.5
18 80 F 4 356 265 26 283 24 40 1.3 13 5 2 8 13.2 12.8 13.4 8.9 14.7 9.3 13.8 10.4
19 81 F 3 128 53 59 156 90 105 0.4 22 5 0 10 17.0 8.2 16.8 21.2 20.7 21.2 18.2 16.8
20 83 F 3 100 37 63 134 81 99 0.6 30 9 2 17 14.0 4.0 13.5 8.3 13.5 7.9 13.7 6.7
21 68 M 3 175 70 60 181 48 68 0.9 32 8 7 19 18.3 2.9 18.4 10.9 25.4 11.2 20.7 8.3
22 76 M 4 199 132 34 237 30 55 1.0 12 0 1 4 20.5 13.0 22.1 14.3 18.8 14.1 20.5 13.8
23 87 M 4 227 166 27 283 35 55 0.6 16 2 9 9 12.0 6.2 11.7 10.6 10.7 11.1 11.5 9.2
24 78 F 3 80 26 67 87 77 87 0.6 8 3 0 5 20.0 12.8 21.4 19.1 20.2 19.2 20.5 17.1
25 83 M 3 89 32 64 149 14 26 1.3 20 0 0 9 19.8 5.0 19.6 18.3 19.2 18.3 19.5 13.9
26 65 F 3 134 60 55 155 50 76 0.8 13 5 3 8 24.6 17.0 24.3 17.8 24.2 18.2 24.4 17.7
27 87 M 1 150 54 64 141 31 48 0.8 3 3 0 2 23.5 25.3 23.5 15.0 14.3 14.9 20.4 18.3
28 67 M 3 188 86 54 236 61 91 0.6 16 0 0 7 18.0 11.8 18.0 14.8 14.5 13.1 16.8 13.3
29 73 M 3 167 72 57 211 59 73 0.8 21 1 4 10 11.3 3.0 10.9 29.3 26.5 31.4 16.2 21.2
30 77 F 3 148 62 58 136 23 32 1.2 20 2 2 9 10.0 6.0 10.0 17.6 20.3 19.0 13.4 14.2
Mean 78 17 m 152 73 55 190 53 75 0.79 14.4 3.4 2.1 7.7 17.0 11.6 17.0 16.9 19.1 17.4 17.7 15.4
SD 7 55 47 10 63 20 24 0.23 8.7 3.0 3.0 4.6 5.1 7.0 5.3 6.5 5.0 7.7 4.3 6.1

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Dec 1, 2016 | Posted by in CARDIOLOGY | Comments Off on Myocardial Deformation Imaging by Two-Dimensional Speckle-Tracking Echocardiography in Comparison to Late Gadolinium Enhancement Cardiac Magnetic Resonance for Analysis of Myocardial Fibrosis in Severe Aortic Stenosis

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