Non-invasive left ventricle strain-volume-pressure loops in asymptomatic significant aortic regurgitation and their role in predicting the need for aortic valve surgery

Severe aortic regurgitation (AR) causes irreversible myocardial damage due to left ventricular (LV) pressure and volume overload. It often occurs before fulfilling the criteria for aortic valve surgery indication (AVSi) as specified in the guidelines. Developing cost-effective imaging markers for identifying the initial impacts of pressure-volume overload due to AR is crucial.

To analyze the correlation between baseline strain-volume-pressure loops (SVPL) surface area and the prediction of the onset of AVSi in asymptomatic patients with significant AR and preserved LV ejection fraction (LVEF).

This prospective multicenter study consisted of 95 consecutive patients (84.1% male, 45 ± 14 years) with asymptomatic significant (≥moderate-severe) AR, in sinus rhythm, and preserved LVEF > 50%, who did not have any indication for aortic valve surgery as per current guidelines. Comprehensive echocardiography was analyzed by an experienced operator blinded to the clinical outcome. SVPL and their surface area were analyzed using customized software.

During a median follow-up of 1375 [interquartile range 1041–1783] days, 34 (36%) patients developed the class I AVSi, i.e., either symptoms or LV dysfunction. At baseline, gender, age, LVEF, LV end-systolic diameter index (LVESDi), and global longitudinal strain did not differ significantly between groups. The SVPL surface area was higher in the patients who developed the indication for surgery in the follow-up (p<0.001) (Figure 1). In a multivariate Cox regression analysis adjusted to age, gender, LVEF, and LVESDi, the patients with an elevated SVPL surface area presented a 4.560 [95% CI 2.138-9.729; p<0.001] higher chance to develop the AVSi in the follow-up (Figure 2).

The non-invasive strain-volume-pressure loop indicates early changes in LV geometry and function caused by chronic pressure-volume overload in significant AR. Patients with increased SVPL surface area are at a higher risk of developing early indications for aortic valve surgery.