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Usefulness of Electrocardiographic Strain to Predict Survival After Surgical Aortic Valve Replacement for Aortic Stenosis

      Electrocardiographic (ECG) strain has been reported as a specific marker of midwall left ventricular (LV) myocardial fibrosis, predictive of adverse clinical outcomes in aortic stenosis (AS), but its prognostic impact after aortic valve replacement (AVR) is unknown. We aimed to assess the impact of ECG strain on long-term mortality after surgical AVR for AS. From January 2005 to January 2014, patients with interpretable preoperative ECG who underwent isolated AVR for AS were included. ECG strain was defined as ≥1-mm concave downslopping ST-segment depression with asymmetrical T-wave inversion in lateral leads. Mortality was assessed over a follow-up period of 4.8 ± 2.7 years. Among the 390 patients included, 110 had ECG strain (28%). They had significantly lower body mass index, higher mean transaortic pressure gradient and Cornell-product ECG LV hypertrophy than in those without ECG strain. There was also a trend for lower LV ejection fraction in patients with ECG strain as compared with those without. Patients with ECG strain had significantly lower 8-year survival than those without. ECG strain remained associated with reduced survival both in patients with and without LV hypertrophy (p <0.0001 for both). After adjustment, ECG strain remained a strong and independent determinant of long-term survival (hazard ratio 4.4, p <0.0001). Similar results were found in patients with LV hypertrophy or without LV hypertrophy. In the multivariate model, the addition of ECG strain provided incremental prognostic value (p <0.0001). In conclusion, in patients with AS, ECG strain is associated with 4-fold increased risk of long-term mortality after isolated AVR, regardless of preoperative LV hypertrophy.
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      References

        • Greve A.M.
        • Gerdts E.
        • Boman K.
        • Gohlke-Baerwolf C.
        • Rossebø A.B.
        • Hammer-Hansen S.
        • Køber L.
        • Willenheimer R.
        • Wachtell K.
        Differences in cardiovascular risk profile between electrocardiographic hypertrophy versus strain in asymptomatic patients with aortic stenosis (from SEAS data).
        Am J Cardiol. 2011; 108: 541-547
        • Shah A.S.V.
        • Chin C.W.L.
        • Vassiliou V.
        • Cowell S.J.
        • Doris M.
        • Kwok T.C.
        • Semple S.
        • Zamvar V.
        • White A.C.
        • McKillop G.
        • Boon N.A.
        • Prasad S.K.
        • Mills N.L.
        • Newby D.E.
        • Dweck M.R.
        Left ventricular hypertrophy with strain and aortic stenosis.
        Circulation. 2014; 130: 1607-1616
        • Greve A.M.
        • Boman K.
        • Gohlke-Baerwolf C.
        • Kesäniemi Y.A.
        • Nienaber C.
        • Ray S.
        • Egstrup K.
        • Rossebø A.B.
        • Devereux R.B.
        • Køber L.
        • Willenheimer R.
        • Wachtell K.
        Clinical implications of electrocardiographic left ventricular strain and hypertrophy in asymptomatic patients with aortic stenosis: the Simvastatin and Ezetimibe in Aortic Stenosis study.
        Circulation. 2012; 125: 346-353
        • Lund O.
        • Nielsen T.T.
        • Emmertsen K.
        • Flø C.
        • Rasmussen B.
        • Jensen F.T.
        • Pilegaard H.K.
        • Kristensen L.H.
        • Hansen O.K.
        Mortality and worsening of prognostic profile during waiting time for valve replacement in aortic stenosis.
        Thorac Cardiovasc Surg. 1996; 44: 289-295
        • Chin C.W.L.
        • Messika-Zeitoun D.
        • Shah A.S.V.
        • Lefevre G.
        • Bailleul S.
        • Yeung E.N.W.
        • Koo M.
        • Mirsadraee S.
        • Mathieu T.
        • Semple S.I.
        • Mills N.L.
        • Vahanian A.
        • Newby D.E.
        • Dweck M.R.
        A clinical risk score of myocardial fibrosis predicts adverse outcomes in aortic stenosis.
        Eur Heart J. 2016; 37: 713-723
        • Devereux R.B.
        • Reichek N.
        Repolarization abnormalities of left ventricular hypertrophy. Clinical, echocardiographic and hemodynamic correlates.
        J Electrocardiol. 1982; 15: 47-53
        • Okin P.M.
        • Devereux R.B.
        • Fabsitz R.R.
        • Lee E.T.
        • Galloway J.M.
        • Howard B.V.
        • Strong Heart Study
        Quantitative assessment of electrocardiographic strain predicts increased left ventricular mass: the Strong Heart Study.
        J Am Coll Cardiol. 2002; 40: 1395-1400
        • Okin P.M.
        • Devereux R.B.
        • Nieminen M.S.
        • Jern S.
        • Oikarinen L.
        • Viitasalo M.
        • Toivonen L.
        • Kjeldsen S.E.
        • Julius S.
        • Dahlöf B.
        Relationship of the electrocardiographic strain pattern to left ventricular structure and function in hypertensive patients: the LIFE study. Losartan Intervention For Endpoint.
        J Am Coll Cardiol. 2001; 38: 514-520
        • Pringle S.D.
        • Macfarlane P.W.
        • McKillop J.H.
        • Lorimer A.R.
        • Dunn F.G.
        Pathophysiologic assessment of left ventricular hypertrophy and strain in asymptomatic patients with essential hypertension.
        J Am Coll Cardiol. 1989; 13: 1377-1381
        • Sokolow M.
        • Perloff D.
        The prognosis of essential hypertension treated conservatively.
        Circulation. 1961; 23: 697-713
        • Verdecchia P.
        • Schillaci G.
        • Borgioni C.
        • Ciucci A.
        • Gattobigio R.
        • Zampi I.
        • Porcellati C.
        Prognostic value of a new electrocardiographic method for diagnosis of left ventricular hypertrophy in essential hypertension.
        J Am Coll Cardiol. 1998; 31: 383-390
        • Kannel W.B.
        • Gordon T.
        • Offutt D.
        Left ventricular hypertrophy by electrocardiogram. Prevalence, incidence, and mortality in the Framingham study.
        Ann Intern Med. 1969; 71: 89-105
        • Kannel W.B.
        Prevalence and natural history of electrocardiographic left ventricular hypertrophy.
        Am J Med. 1983; 75: 4-11
        • Roman M.J.
        • Kligfield P.
        • Devereux R.B.
        • Niles N.W.
        • Hochreiter C.
        • Halle A.
        • Sato N.
        • Borer J.S.
        Geometric and functional correlates of electrocardiographic repolarization and voltage abnormalities in aortic regurgitation.
        J Am Coll Cardiol. 1987; 9: 500-508
        • Villari B.
        • Hess O.M.
        • Moccetti D.
        • Vassalli G.
        • Krayenbuehl H.P.
        Effect of progression of left ventricular hypertrophy on coronary artery dimensions in aortic valve disease.
        J Am Coll Cardiol. 1992; 20: 1073-1079
        • Tomanek R.J.
        • Palmer P.J.
        • Peiffer G.L.
        • Schreiber K.L.
        • Eastham C.L.
        • Marcus M.L.
        Morphometry of canine coronary arteries, arterioles, and capillaries during hypertension and left ventricular hypertrophy.
        Circ Res. 1986; 58: 38-46
        • Nakamura N.
        • Hirata K.
        • Imanishi T.
        • Kuroi A.
        • Arita Y.
        • Ikejima H.
        • Tsujioka H.
        • Takemoto K.
        • Tanimoto T.
        • Kitabata H.
        • Takarada S.
        • Kubo T.
        • Mizukoshi M.
        • Tanaka A.
        • Arita M.
        • Akasaka T.
        Electrocardiographic strain and endomyocardial radial strain in hypertensive patients.
        Int J Cardiol. 2011; 150: 319-324
        • Hittinger L.
        • Shannon R.P.
        • Bishop S.P.
        • Gelpi R.J.
        • Vatner S.F.
        Subendomyocardial exhaustion of blood flow reserve and increased fibrosis in conscious dogs with heart failure.
        Circ Res. 1989; 65: 971-980
        • Dalen B.M.
        • van Tzikas A.
        • Soliman O.I.I.
        • Heuvelman H.J.
        • Vletter W.B.
        • Ten Cate F.J.
        • Geleijnse M.L.
        Assessment of subendocardial contractile function in aortic stenosis: a study using speckle tracking echocardiography.
        Echocardiography. 2013; 30: 293-300
        • McLenachan J.M.
        • Henderson E.
        • Morris K.I.
        • Dargie H.J.
        Ventricular arrhythmias in patients with hypertensive left ventricular hypertrophy.
        N Engl J Med. 1987; 317: 787-792
        • Vahanian A.
        • Alfieri O.
        • Andreotti F.
        • Antunes M.J.
        • Baron-Esquivias G.
        • Baumgartner H.
        • Borger M.A.
        • Carrel T.P.
        • De Bonis M.
        • Evangelista A.
        • Falk V.
        • Iung B.
        • Lancellotti P.
        • Pierard L.
        • Price S.
        • Schafers H.J.
        • Schuler G.
        • Stepinska J.
        • Swedberg K.
        • Takkenberg J.
        • von Oppell U.O.
        • Windecker S.
        • Zamorano J.L.
        • Zembala M.
        • Bax J.J.
        • Baumgartner H.
        • Ceconi C.
        • Dean V.
        • Deaton C.
        • Fagard R.
        • Funck-Brentano C.
        • Hasdai D.
        • Hoes A.
        • Kirchhof P.
        • Knuuti J.
        • Kolh P.
        • McDonagh T.
        • Moulin C.
        • Popescu B.A.
        • Reiner Z.
        • Sechtem U.
        • Sirnes P.A.
        • Tendera M.
        • Torbicki A.
        • Vahanian A.
        • Windecker S.
        • Von Segesser L.
        • Badano L.P.
        • Bunc M.
        • Claeys M.J.
        • Drinkovic N.
        • Filippatos G.
        • Habib G.
        • Kappetein A.P.
        • Kassab R.
        • Lip G.Y.
        • Moat N.
        • Nickenig G.
        • Otto C.M.
        • Pepper J.
        • Piazza N.
        • Pieper P.G.
        • Rosenhek R.
        • Shuka N.
        • Schwammenthal E.
        • Schwitter J.
        • Tornos Mas P.
        • Trindade P.T.
        • Walther T.
        • The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC)
        • European Association for Cardio-Thoracic Surgery (EACTS)
        Guidelines on the management of valvular heart disease (version 2012).
        Eur Heart J. 2012; 33: 2451-2496
        • Nishimura R.A.
        • Otto C.M.
        • Bonow R.O.
        • Carabello B.A.
        • Erwin III, J.P.
        • Guyton R.A.
        • O'Gara P.T.
        • Ruiz C.E.
        • Skubas N.J.
        • Sorajja P.
        • Sundt III, T.M.
        • Thomas J.D.
        2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines.
        Circulation. 2014; 129: 2440-2449
        • Lauer M.S.
        • Blackstone E.H.
        • Young J.B.
        • Topol E.J.
        Cause of death in clinical research: time for a reassessment?.
        J Am Coll Cardiol. 1999; 34: 618-620