Korean J Anesthesiol Search

CLOSE


Korean J Anesthesiol > Volume 75(5); 2022 > Article
Park: Application of a new modality for assessing left ventricular function: can strain replace ejection fraction?
The evaluation of left ventricular (LV) systolic function is vital for guiding treatment strategies and predicting outcomes, especially for surgical treatments [1]. Traditionally, LV ejection fraction (LVEF) has been one of the most important markers for evaluating LV systolic function [2]. However, LVEF cannot discriminate between the different effects of load on myocardial contractility, resulting in falsely high LVEF in mitral regurgitation (MR) or falsely low LVEF in aortic stenosis and thus low accuracy for predicting treatment outcomes [3].
Recently, LV longitudinal strain (LVLS) was introduced as a new marker to evaluate LV systolic function and has been demonstrated to have postoperative prognostic value for various cardiac diseases [47]. LVLS has been found to be able to detect subtle ventricular dysfunction that LVEF cannot detect [8]. Several studies have reported that LVLS is independently associated with postoperative survival in valvular surgery, especially in corrective surgery for MR. Given the propensity for the LVEF to be overestimated in MR, impaired LV systolic function may be masked in patients with severe MR [9,10].
In this issue of the Korean Journal of Anesthesiology, Nam et al. [11] investigated the predictive value of apical four-chamber LVLS for postoperative survival in patients with various types of valvular heart disease. In this retrospective observational study of 1,773 patients, the authors demonstrated the long-term prognostic value of LVLS measured in the apical four-chamber view after heart valve surgery. During a median follow-up of 27 months, preoperative apical four-chamber LVLS was significantly associated with postoperative all-cause mortality, whereas LVEF was not. Moreover, LVLS showed a significant incremental prognostic value over LVEF and traditional prognostic factors (e.g., age, sex, Charlson comorbidity index, pulmonary hypertension, New York Heart Association [NYHA] classification, atrial fibrillation, and presence of valvular diseases) for predicting all-cause mortality. The authors showed that apical four-chamber LVLS might be a useful marker for predicting mortality after valvular surgery. This study provides an important rationale for incorporating longitudinal strain analyses into routine clinical practice.
This study shows a distinct view and has multiple advantages over previous studies. First, unlike the commonly used LVLS, measurements from one echocardiographic view (i.e., apical four-chamber view) were used. Measuring LVLS only in the apical four-chamber view without additional echocardiographic views (e.g., longitudinal two-chamber or three-chamber view) could thus have predictive value for postoperative outcomes with reasonable feasibility and reliability. Second, the relationship between LVLS and long-term mortality shown in this study was not limited to patients with MR. Patients with different valvular heart diseases and thus different pathophysiologies were analyzed together. Third, compared to previous studies [9,10,12], in this study, a relatively large number of patients who underwent valvular heart surgery were analyzed.
Although LVLS directly reflects myocardial shortening and is less dependent on loading conditions than LVEF [12], strain remains a load-dependent measure [13]. Despite some limitations, this study showed that apical four-chamber LVLS could be a useful alternative to conventional LV systolic function markers for predicting postoperative outcomes in patients undergoing heart valve surgery. An apical four-chamber LVLS can be easily implemented. In addition, it is useful when the imaging quality from the apical two- or three-chamber view is poor. Although LVEF remains a valuable marker of LV function, the addition of LVLS improves risk assessment.

NOTES

Funding

None.

Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

References

1. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017; 38: 2739-91.
crossref pmid
2. Shim CY. Preoperative cardiac evaluation with transthoracic echocardiography before non-cardiac surgery. Korean J Anesthesiol 2017; 70: 390-7.
crossref pdf
3. Nesbitt GC, Mankad S, Oh JK. Strain imaging in echocardiography: methods and clinical applications. Int J Cardiovasc Imaging 2009; 25 Suppl 1: 9-22.
crossref pmid pdf
4. Klaeboe LG, Edvardsen T. Echocardiographic assessment of left ventricular systolic function. J Echocardiogr 2019; 17: 10-6.
crossref pdf
5. Park JJ, Park JB, Park JH, Cho GY. Global longitudinal strain to predict mortality in patients with acute heart failure. J Am Coll Cardiol 2018; 71: 1947-57.
crossref pmid
6. Ersbøll M, Valeur N, Mogensen UM, Andersen MJ, Møller JE, Velazquez EJ, et al. Prediction of all-cause mortality and heart failure admissions from global left ventricular longitudinal strain in patients with acute myocardial infarction and preserved left ventricular ejection fraction. J Am Coll Cardiol 2013; 61: 2365-73.
crossref pmid
7. Liu H, Pozios I, Haileselassie B, Nowbar A, Sorensen LL, Phillip S, et al. Role of global longitudinal strain in predicting outcomes in hypertrophic cardiomyopathy. Am J Cardiol 2017; 120: 670-5.
crossref pmid
8. Luis SA, Chan J, Pellikka PA. Echocardiographic assessment of left ventricular systolic function: an overview of contemporary techniques, including speckle-tracking echocardiography. Mayo Clin Proc 2019; 94: 125-38.
crossref pmid
9. Hiemstra YL, Tomsic A, van Wijngaarden SE, Palmen M, Klautz RJ, Bax JJ, et al. Prognostic value of global longitudinal strain and etiology after surgery for primary mitral regurgitation. JACC Cardiovasc Imaging 2020; 13: 577-85.
crossref pmid
10. Kim HM, Cho GY, Hwang IC, Choi HM, Park JB, Yoon YE, et al. Myocardial strain in prediction of outcomes after surgery for severe mitral regurgitation. JACC Cardiovasc Imaging 2018; 11: 1235-44.
crossref pmid
11. Nam JS, Chin JH, Kang HU, Kim J, Joung KW, Choi IC. Prognostic value of left ventricular apical four-chamber longitudinal strain after heart valve surgery in real-world practice. Korean J Anesthesiol 2022; 75: 417-27.
crossref pmid
12. Namazi F, van der Bijl P, Hirasawa K, Kamperidis V, van Wijngaarden SE, Mertens B, et al. Prognostic value of left ventricular global longitudinal strain in patients with secondary mitral regurgitation. J Am Coll Cardiol 2020; 75: 750-8.
crossref pmid
13. Hurlburt HM, Aurigemma GP, Hill JC, Narayanan A, Gaasch WH, Vinch CS, et al. Direct ultrasound measurement of longitudinal, circumferential, and radial strain using 2-dimensional strain imaging in normal adults. Echocardiography 2007; 24: 723-31.
crossref pmid


ABOUT
ARTICLE CATEGORY

Browse all articles >

BROWSE ARTICLES
AUTHOR INFORMATION
Editorial Office
101-3503, Lotte Castle President, 109 Mapo-daero, Mapo-gu, Seoul 04146, Korea
Tel: +82-2-792-5128    Fax: +82-2-792-4089    E-mail: journal@anesthesia.or.kr                

Copyright © 2022 by Korean Society of Anesthesiologists.

Developed in M2PI

Close layer
prev next