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Effect of valve replacement for aortic stenosis on ventricular function
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

BackgroundAortic stenosis (AS) is the commonest valve disease in the West. Aortic valve replacement (AVR) remains the only available management for AS and results in improved symptoms and recovery of ventricular functions. In addition, it is well known that AVR results in disruption of LV function mainly in the form of reversal of septal motion as well as depression of right ventricular (RV) systolic function. The aim of this thesis was to study, in detail, the early and mid-term response of ventricular function to AVR procedures (surgical and TAVI) as well as post operative patients’ exercise capacity.

MethodsWe studied LV and RV function by Doppler echocardiography and speckle tracking echocardiography (STE) in the following 4 groups; (1) 30 severe AS patients (age 62±11 years, 19 male) with normal LV ejection fraction (EF) who underwent AVR, (2) 20 severe AS patients (age 79±6 years, 14 male) who underwent TAVI, (3) 30 healthy controls (age 63±11 years, 16 male), (4) 21 healthy controls (age 57±9 years, 14 male) who underwent exercise echocardiography.

Results: After one week of TAVI, the septal radial motion and RV tricuspid annulus peak systolic excursion (TAPSE) were not different from before, while surgical AVR had significantly reversed septal radial motion and TAPSE dropped by 70% compared to before. The extent of the reversed septal motion correlated with that of TAPSE (r=0.78, p<0.001) in the patients as a whole after AVR and TAVI (Study I). Compared with controls, the LV twist function was increased in AS patients before and normalized after 6 months of surgical AVR. In controls, the LV twist correlated with LV fractional shortening (r=0.81, p<0.001), a relationship which became weak in patients before (r=0.52, p<0.01) and after AVR (r=0.34, p=ns) (Study II). After 6 months of surgical AVR, the reversed septal radial motion was still significantly lower than before. The septal peak displacement also decreased and its time became prolonged. In contrast, the LV lateral wall peak displacement increased and the time to peak displacement was early. The accentuated lateral wall peak displacement correlated with the septal peak displacement time delay (r=0.60, p<0.001) and septal-lateral time delay (r=0.64, p<0.001) (Study III). In 21 surgical AVR patients who performed exercise echocardiography, the LV function was normal at rest but different from controls with exercise. At peak exercise, oxygen consumption (pVO2) was lower in patients than controls. Although patients could achieve cardiac output (CO) and heart rate (HR) similar to controls at peak exercise, the LV systolic and early diastolic myocardial velocities and strain rate as well as their delta changes were significantly lower than controls. pVO2 correlated with peak exercise LV myocardial function in the patients group only, and the systolic global longitudinal strain rate (GLSRs) at peak exercise was the only independent predictor of pVO2 in multivariate regression analysis (p=0.03) (Study IV).

Conclusion: Surgical AVR is an effective treatment for AS patients, but results in reversed septal radial motion and reduced TAPSE. The newly developed TAVI procedure maintains RV function which results in preservation of septal radial motion. In AS, the LV twist function is exaggerated, normalizes after AVR but loses its relationship with basal LV function. While the reversed septal motion results in decreased and delayed septal longitudinal displacement which is compensated for by the accentuated lateral wall displacement and the time early. These patients remain suffering from limited exercise capacity years after AVR.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2011. , 68 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1442
Keyword [en]
Aortic stenosis, aortic valve replacement, echocardiography, speckle tracking, exercise echocardiography, ventricular function, septal radial motion, twist, displacement, strain, strain rate
National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
URN: urn:nbn:se:umu:diva-46809ISBN: 978-91-7459-274-0 (print)OAI: oai:DiVA.org:umu-46809DiVA: diva2:441580
Public defence
2011-10-14, sal 916, våning 9, UnodB9, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2011-09-23 Created: 2011-09-15 Last updated: 2011-09-23Bibliographically approved
List of papers
1. Trans-catheter aortic valve implantation: early recovery of left and preservation of right ventricular function
Open this publication in new window or tab >>Trans-catheter aortic valve implantation: early recovery of left and preservation of right ventricular function
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2011 (English)In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 12, no 1, 35-39 p.Article in journal (Refereed) Published
Abstract [en]

This study aimed to assess the early effect of trans-catheter aortic valve implantation (TAVI) on right (RV) and left ventricular (LV) function in severe aortic stenosis (AS) patients. Twenty AS patients (age 79±6 years) were examined before, one week and six weeks after TAVI using Doppler echocardiography. LV ejection fraction (EF), long-axis [mitral annular plane systolic excursion (MAPSE)] and RV long-axis [tricuspid annular plane systolic excursion (TAPSE)] function, septal radial motion were studied. Results were compared with 30 AS patients before and one week after aortic valve replacement (AVR) as well as 30 normals (reference group). Before TAVI, LVEF was reduced and E/A was higher than the reference and AVR groups (P<0.05 for all). MAPSE, TAPSE and septal motion were equally reduced in TAVI and AVR patients (P<0.05 for all). One week after the TAVI, EF increased in patients with values <50% before the procedure. In contrast, AVR resulted in reversed septal motion (P<0.001) and depressed TAPSE (P<0.001). The extent of reversed septal motion correlated with that of TAPSE in the patients group as a whole after procedures (r=0.78, P<0.001). Six weeks after TAVI, RV function remained unchanged, but LVEF increased and E/A decreased (P<0.05 for both). Thus, TAVI procedure results in significant early improvement of LV systolic and diastolic function particularly in patients with reduced EF and preserves RV systolic function.

National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-39543 (URN)10.1510/icvts.2010.251348 (DOI)20956401 (PubMedID)
Available from: 2011-01-31 Created: 2011-01-31 Last updated: 2017-12-11Bibliographically approved
2. Aortic valve replacement normalizes left ventricular twist function
Open this publication in new window or tab >>Aortic valve replacement normalizes left ventricular twist function
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2011 (English)In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 12, no 5, 701-706 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to assess the effect of aortic valve replacement (AVR) on left ventricular (LV) twist function. We studied 28 severe aortic stenosis (AS) patients with normal LV ejection fraction (EF) before and six months after AVR. LV long axis function was assessed using M-mode and tissue Doppler and twist function using speckle tracking echocardiography. The data were compared with 28 age and sex-matched normal controls. In patients, LVEF remained unchanged after AVR. LV long axis function was reduced before surgery but normalized after AVR. LV twist was increased before (19.7 ± 5.7° vs. 12.9 ± 3.2°, P<0.001) and normalized after AVR (14.4 ± 5.2 °, P < 0.001). In normals, LV twist correlated with LV fractional shortening (r = 0.81, P<0.001) but not with EF. This relationship was reversed in patients before ( r= 0.52, P < 0.01) and after AVR (r = 0.34, P = ns). In patients with severe AS and normal EF, LV twist is exaggerated suggesting potential compensation for the reduced long axis function. These disturbances normalize within six months of AVR but lose their relationship with basal LV function.

Keyword
Aortic stenosis; Aortic valve replacement; Left ventricular function; Twist
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-45905 (URN)10.1510/icvts.2010.262303 (DOI)21303867 (PubMedID)
Available from: 2011-08-19 Created: 2011-08-19 Last updated: 2017-12-08Bibliographically approved
3. Accentuated left ventricular lateral wall function compensates for septal dyssynchrony after valve replacement for aortic stenosis
Open this publication in new window or tab >>Accentuated left ventricular lateral wall function compensates for septal dyssynchrony after valve replacement for aortic stenosis
2013 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 164, no 3, 339-344 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The interventricular septal motion becomes reversed after aortic valve replacement (AVR) for aortic stenosis (AS) despite maintained stroke volume (SV). We hypothesis that left ventricular (LV) lateral wall compensates for such disturbances, in order to secure normal SV. METHODS: We studied 29 severe AS patients (age 63±11years, 18 males) with normal ejection fraction (EF) before, 6months and 12months after AVR and compared them with 29 age- and gender-matched controls, using speckle tracking echocardiography. RESULTS: In patients, the LVEF and SV remained unchanged throughout. Before AVR, the septal radial motion, septal and lateral strain were reduced (p<0.001). Peak septal and lateral displacements, times from QRS to peak displacement were all not different from controls. Six months after AVR, septal radial motion reversed (p<0.001), lateral strain increased (p<0.05), peak septal displacement reduced (p<0.01) while lateral displacement increased (p<0.05). Time to peak septal displacement delayed (p<0.01) in contrast to lateral displacement which became early (p<0.05), resulting in a significant septal-lateral time delay (p<0.01). The accentuation of LV lateral wall correlated with septal displacement time delay (r=0.60, p<0.001) and septal-lateral time delay (r=0.64, p<0.001). SV correlated with lateral displacement (r=0.39, p<0.05). The systolic strain was correlated with opposite wall displacement (p<0.05 for both). There was no correlation between these measurements before and 12month after AVR. CONCLUSIONS: Accentuated lateral wall displacement compensates for septal dyssynchrony in order to maintain normal LVEF and SV. The continuing recovery of these disturbances 12months after complete mass regression suggests an ongoing reverse remodeling.

Keyword
aortic valve replacement, displacement, dyssynchrony, remodeling
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-45862 (URN)10.1016/j.ijcard.2011.07.031 (DOI)000316599700022 ()21807426 (PubMedID)
Note

Included in thesis in manuscript form.

Available from: 2011-08-19 Created: 2011-08-19 Last updated: 2017-12-08Bibliographically approved
4. Residual compromised myocardial contractile reserve after valve replacement for aortic stenosis
Open this publication in new window or tab >>Residual compromised myocardial contractile reserve after valve replacement for aortic stenosis
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2012 (English)In: European Heart Journal Cardiovascular Imaging, ISSN 2047-2404, E-ISSN 2047-2412, Vol. 13, no 4, 353-360 p.Article in journal (Refereed) Published
Abstract [en]

Objective: Despite recovery of left ventricular (LV) function and morphology after aortic valve replacement (AVR) for aortic stenosis (AS), its relationship with exercise capacity remains unknown. Twenty-one AVR patients (age 61 +/- 12 years, 14 male) with normal ejection fraction (EF, 64 +/- 7%) and 21 age- and sex-matched controls (57 +/- 9 years, 10 male, EF 68 +/- 8%) were studied.Methods and results: All subjects performed semi-supine bicycle exercise and speckle tracking echocardiography (STE) study. Peak oxygen consumption (pVO(2)) was collected during semi-supine bicycle exercise. Systolic (GLSRs) and early diastolic (GLSRe) longitudinal strain rate using STE and Doppler echocardiographic parameters were measured at rest, submaximal, peak exercise, and 4 min after exercise. The two groups had comparable resting echocardiographic measurements. At peak exercise, pVO(2) was lower in patients than controls (18.5 +/- 4.5 vs. 22.1 +/- 4.3 L/min/kg, P < 0.05). GLSRs (0.98 +/- 0.28 vs. 1.55 +/- 0.30 1/s, P < 0.001), septal Sm (7.9 +/- 1.4 vs. 11.1 +/- 2.3 cm/s, P < 0.001) and their changes between rest and peak exercise (Delta GLSRs: 0.16 +/- 0.33 vs. 0.68 +/- 0.27 1/s, P < 0.001; Delta Sm 2.29 +/- 2.23 vs. 4.63 +/- 2.29 cm/s, P < 0.01) were significantly lower in patients than controls. There was no correlation between pVO(2) and any echocardiographic measurements in controls. In patients, pVO(2) correlated with peak exercise GLSRs (r = 0.60, P = 0.0007), septal Sm (r = 0.65, P = 0.002), and Em (r = 0.57, P = 0.009). In a multivariate model, peak exercise GLSRs (beta = 7.18, P = 0.03) was the only independent predictor of pVO(2) in the patients group.Conclusion: Exercise capacity is subnormal after AVR for AS, irrespective of normal LVEF suggesting residual compromised myocardial functional reserve.

Place, publisher, year, edition, pages
Oxford: Oxford University Press, 2012
Keyword
Exercise echocardiography, Aortic valve replacement, Strain rate, Reserve
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-47565 (URN)10.1093/ejechocard/jer246 (DOI)000303227200013 ()
Available from: 2011-09-23 Created: 2011-09-23 Last updated: 2017-12-08Bibliographically approved

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