International Journal of Cardiology and Cardiovascular Research

IJCCR
Vol. 4(1), pp. 045-051, January, 2018. © www.premierpublishers.org, ISSN: 3102-9869

Case Study

A Speckle Tracking Echocardiographic Study for Correlation

Between Global Left Ventricular Strain and Severity of Aortic
Stenosis
1Wael Ahmed Maklad*, 2Mahmoud Shawky Abd El Moneum
1,2
Department of Cardiology, Faculty of Medicine, Banha University, Egypt

Global longitudinal strain (GLS) measured by Two-dimensional speckle tracking imaging (2D-STI)
has been shown to be useful for assessing subtle changes in the left ventricular function with
increasing severity of aortic stenosis (AS) in patients with preserved left ventricular ejection
fraction (LVEF). To evaluate the relation between the severity of valve stenosis and GLS measured
by 2D-STI in AS patients with normal LVEF. We studied 65 subjects (age, 53_75 years) with normal
LVEF (≥50%) but without overt coronary artery disease. Patients were stratified into four groups
(control, mild, moderate and severe AS), the clinical characteristics and echocardiographic
findings were compared among the groups. Using dedicated software, we measured GLS in the
apical four, two and three -chamber views. LVEF was not significantly different among the four
groups. However, GLS showed significant differences among the four groups (controls;18.9±1.4,
mild: 18.8±1.3, moderate: 15.35±1.6and severe: 12.42±1.4, ANOVA P = 0.001), GLS was
significantly correlated with AVA, mean PG and LV mass index. Despite unchanged LVEF, GLS
gradually decreased as severity of AS increases. GLS measured by 2D-STI is useful to assess
subtle changes in LV function in AS patients.

Keywords: aortic stenosis, left ventricle, echocardiography, left ventricular function.

INTRODUCTION

Aortic Stenosis (AS) has become the most frequent
valvular heart disease in the western world with an
increasing prevalence in the elderly, while in older subjects
it is a major cause of morbidity. (Carabello BA et al.,
2009:956-66)
Several studies have demonstrated that the development
and progression of AS is at least partially an active
atherosclerotic process including infiltration of
inflammatory cells, extracellular lipid depositions, and
active calcification. (Otto CM et al., 2014:744-756)
an excessive rise in end-diastolic pressure leading to
pulmonary congestion. Alternatively, exertional symptoms
may be a result of the limited ability to increase cardiac
output with exercise. More severe exertional dyspnea, with
orthopnea, paroxysmal nocturnal dyspnea, and pulmonary
edema reflects varying degrees of pulmonary venous
hypertension. These are relatively late symptoms in
patients with AS, and intervention now is typically
undertaken before this disease stage. (Rosenhek R et al.,
2009:127-154)

The most common clinical presentation in patients with a

known diagnosis of AS who are followed prospectively is a *Corresponding author: Dr. Wael Maklad, Department of
gradual decrease in exercise tolerance, fatigue, or Cardiology, Faculty of Medicine, Banha University, Egypt.
dyspnea on exertion due to LV diastolic dysfunction, with Tel: 00201009537864, Email: husseine86@gmail.com
A Speckle Tracking Echocardiographic Study for Correlation Between Global Left Ventricular Strain and Severity of Aortic Stenosis
Maklad and Abd El Moneum 046
It is important to follow not only the progression of aortic
valve obstruction, but also the progression of LV
dysfunction by echocardiography in AS patients. Left
ventricular ejection fraction (LVEF) is the most common
measure of LV systolic function. However, it often remains
normal even in symptomatic patients with severe AS.
Thus, it is impossible to assess latent changes in LV
function using only LVEF. Two-dimensional (2D) speckle
tracking echocardiography (STE) is a promising imaging
modality, Similar to tissue Doppler imaging (TDI). It
permits offline calculation of myocardial velocities and
deformation parameters such as strain and strain rate
(SR).
It is well accepted that these parameters provide important
insights into systolic and diastolic function, ischaemia,
myocardial mechanics and many other pathophysiological
processes of the heart. (Pavlopoulos H et al.,
2008:479e91)
In contrast to TDI, STE uses a completely different
algorithm to calculate deformation: by computing
deformation from standard 2D grey scale images, it is
possible to overcome many of the limitations of TDI.
Reisner SA et al(2004) revealed that two-dimensional
speckle-tracking echocardiography (2D-STE) provides a
better characterization of subtle changes in LV function
than LVEF. The aim of the present study was to evaluate
the relation between the severity of valvular obstruction
and GLS measured by 2DSTI in AS patients with
preserved EF.
PATIENTS AND METHODS
Prospective study included 65 patients, 50 of whom with
different degrees of AS & 15 are cardiologicaly free
referred for routine cardiovascular assessment, divided
Figure 1: Apical 4 chambers longitudinal strain curves in a healthy subject.
A Speckle Tracking Echocardiographic Study for Correlation Between Global Left Ventricular Strain and Severity of Aortic Stenosis
into four groups, control(normal), mild, moderate & severe
AS. We excluded patients with mitral valve disease,
coronary artery disease (CAD), patients with LV systolic
dysfunction (ejection fraction (EF %) <50%) and patients
with cardiac rhythm disturbances such as atrial fibrillation
or artificial pacing.
All patients undergo Standard 12 leads surface ECG,
Routine laboratory samples for complete blood count,
kidney function tests, lipid profile, echocardiography to
assess the LV systolic function, complete aortic valve
assessment and evidence of no wall motion abnormalities
at rest, 2D
Speckle tracking Echocardiography (STE): 2D
echocardiography images (transmit/receive 1.9/4.0 MHz)
were obtained from LV apical LAX, 4C, and 2C views with
frame rates of 30–90 frames/s. Digital data were stored
and analyzed off-line. LV endocardial surface was traced
manually, and the speckle tracking width was modified so
as to cover the whole LV wall thickness to obtain curves
for peak longitudinal strain of the Inferior septum and
lateral wall in the apical four-chamber view (4C-PLS), the
Inferior and anterior wall was in the apical two chamber
view (2C-PLS), and the infero lateral and anterior septum
in the apical three-chamber view (3C-PLS). Left ventricular
global longitudinal systolic strain (LV-GLS) was calculated
by averaging the peak systolic values of the 6 LV walls. As
shown in (Figure 1).
Statistical analysis
Data are presented as mean ± SD for continuous data and
as number (%) for categorical data. Between groups
analysis was done using student t-test for continuous data
and Chi-square test, level of evidence was detected to be
significant at P value<0.05 was considered statistically P
value <0.01 was considered highly significant.
 Int. J. Cardiol. Cardiovasc. Res. 047

Table 1: Demographic charactaristics of studied groups:

Demographic variant Control Mild Moderate Severe P value
N=15 N=21 N=11 N=18
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
Age, Years 62.28±8.64 61.28±8.64 62.27±9.36 68.16±7.4 0.23
Gender
Female 5 (33.3%) 15(71.4%) 3(27.3%) 7(38.9%) 0.56
Male 10 (66.7%) 6(28.6%) 3(72.7%) 11(61.1%)
Weight, Kg 81.48±16.24 80.48±16.24 81±10.21 77±13.54 0.73
DiabetesYes
No 8(53.3%) 8 (38.1%) 3(27.3%) 7(38.9%) 0.79
7(46.7%) 13(61.9%) 8(72.8%) 11(61.1%)
Dyslipedemia
Yes 5(33.3%) 4(19%) 1(9.1%) 2(11.1%) 0.67
No 10(66.7%) 71(81%) 10(90.1%) 16(88.9%)
Smoking Status
Yes 6(40%) 5(23.8%) 5(45.5%) 6(33.3%) 0.45
No 9(60%) 16(76.2% 6(54.5%) 12(66.7%)
Data are presented as mean ±SD or number (percent), N= number

Table 2 : laboratory criteria of studied groups:

Lab criteria Control Mild Moderate Severe P value
N=15 N=21 No=11 No=18
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
Hemoglobin 14.5±1.35 13.04±1.32 13.98±1.52 13.22±1.4 0.19
Creatinine 1.23±1.13 1.33±1.03 0.98±0.23 1.2±0.21 0.40
Data are presented as mean ±SD or number (percent)

Table 3:
ECG Variant Control Mild AS Moderate AS Severe AS P value
N=15 N=21 N=11 No=18
LVH
Yes 0 (0%) 0 (0%) 6 (54.5%) 13(72.2%)
NO 15(100%) 21(100%) 5(45.5%) 5(27.8%) 0.001
ST changes
Yes 0 (0%) 0(0%) 2(18.2%) 5(27.8%)
NO 15(100%) 21(100%) 9(81.8%) 13(72.2%) 0.04
LA abnormality
Yes 0 (0%) 0 (0%) 0 (0%) 4(22.2%)
NO 15(100%) 21(100%) 11(100%) 14(77.8%) 0.02
T wave inversion
Yes 0 (0%) 1(4.8%) 4(36.4%) 12(66.7%)
NO 15(100%) 20(95.2%) 7(63.6%) 6(33.3%) 0.001
LVH= left ventricular hypertrophy; LA= left atrium; N= number

RESULTS ECG study

Demographic characteristics
The study included 65 subjects, 53.8% males and 46.2%
females with the mean age 61.28±8.64 years with baseline
clinical characteristics as shown in Table (1). There was
no significant statistical difference between 4 groups (p
value >0.05).
Laboratory investigations
Regarding laboratory investigations in studied groups
there was no significant statistical difference, p value
>0.05. (Table 2)
A Speckle Tracking Echocardiographic Study for Correlation Between Global Left Ventricular Strain and Severity of Aortic Stenosis
Baseline ECG analysis in the studied groups shows
significant statistically ECG changes (LVH, ST changes,
LA abnormality and T wave inversion) with p value less
than 0.05 in severe cases as shown in (Table 3)
Baseline Echocardiographic criteria of the studied
population (Table4):
There is no significant statistical difference between the
four groups as regard internal dimensions, EF, FS, ESV
and EDV, But on the other hand There is significant
statistical difference as regard IVS, PWT, LVMI, LAD and
aortic valve parameters(AVA, PV& MPG) as shown in
table(4).
Maklad and Abd El Moneum 048

Table 4: Baseline Echocardiographic criteria of the studied population:

Echo data Control Mild Moderate Severe P value
No=15 No=21 N=11 N=18
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
LVESD 2.99±0.39 2.95±0.37 3.12±0.27 3.02±0.39 0.41
LVEDD 5±0.34 4.9±0.37 5.26±0.26 5.1±0.33 0.25
LAD 3.2±0.41 3.3±0.31 3.6±0.26 3.9±0.38 0.001
EF 61.01±1.9 61.33±1.79 62.36±3.17 63.89±4.62 0.07
FS 34.22±1.33 34.33±1.23 35.18±1.53 35.5±2.5 0.134
LVMI 115±16.1 117±16.8 118.6±14.6 130.2±2.11 0.007
ESV 34.05±2.80 34.95±2.85 35.72±3.1 32.5±4.7 0.05
EDV 111.7±9.71 112.7±9.51 109±8.33 107.2±8.3 0.16
PWT 0.9±0.09 0.9±0.1 1.1±0.1 1.2±0.06 0.001
IVS 0.9±0.12 1.03±0.11 1.24±0.1 1.4±0.08 0.001
AVA 3.15±0.15 1.13±0.14 0.89±0.08 0.7±0.07 0.001
MPG 6±3.85 15.8±4.88 35.7±5.39 59.4±7.7 0.001
PV 1.77±0.30 2.57±0.27 3.76±0.33 4.7±0.2 0.001
LVEDD; left ventricular end diastolic dimension, LVESD; left ventricular end systolic dimension. LAD; left atrial diameter,
EF; ejection fraction, FS; fractional shortestatisticalning, LVMI; left ventricular mass index. ESV; end systolic volume, EDV;
end diastolic volume, PWT; posterior wall thickness, AVA; aortic valve area. IVS; inter ventricular septum, MPG; mean
pressure gradient, PV; peak velocity.

Speckle tracking criteria of studied groups (Table 5)

There is statistically significant decrease in GLS with DISCUSSION

increasing severity of AS as shown in table (5), and figure
(2). Because of the statistically significant correlation between
AS and LV dysfunction and the higher likelihood of initial
Table 5 : Speckle tracking criteria of studied groups: poor outcomes, it would be beneficial to know the true
prevalence of coronary artery disease in this population
Speckle Control Mild Moderate Severe P and the associated risk factors to stratify patients with AS.
tracking N=15 N=21 N=11 N=18 value It would also be helpful to know who, when, and with which
GLS 18.9±1.4 18.8±1.3 15.35±1.6 12.42±1.4 0.001 test to screen such patients to achieve the most effective
Data are presented as mean ±SD or number (percent), N= prevention of cardiovascular complications in this high-risk
number population. (Carabello et al., 2008; 523-661)

The measurement of global LV function is the most

common indication for echocardiography, and LV
dysfunction is known to be a strong prognostic marker of
adverse outcome most commonly assessed by the
calculation of EF, AS patients with normal left ventricular
ejection fraction (LVEF) are frequently associated with
subclinical LV dysfunction. However, LVEF is not known to
be a sensitive marker for the detection of subclinical LV
systolic dysfunction. The presence of impaired longitudinal
function in AS patients has been reported when using
tissue Doppler imaging or speckle tracking
echocardiography. (Carabello et al., 2008; 523-661)
However, tissue Doppler imaging has its own limitations
including angle dependency and the nature of its
measurement. The development of 2D speckle tracking
Fig 2: comparison between studied groups as regard echocardiography (STE) overcomes some of these
GLS. limitations, and its accuracy and clinical usefulness have
been reported. (Marwick TH et al.,2009:80e4)

A Speckle Tracking Echocardiographic Study for Correlation Between Global Left Ventricular Strain and Severity of Aortic Stenosis

In this study, we demonstrated a significant relationship
between GLS assessed by 2D-STE and AS severity in
patients with normal EF., As the AS severity progresses,
GLS was reduced, whereas EF was unchanged.
In contrary to several studies as the study designed by
Hany Younan (2014) in Cardiology Department, Faculty of
Medicine, Fayoum University, Egypt 2014. included 80
subjects compairing between 50 patients with severe AS
(mean age: 45 ± 9 years) and 30 age-matched healthy
individuals (mean age 43 ± 7 years resulted in significant
reduction in LV-GLS in patients with AS compared to
controls (<0.001), and negatively correlated with left
ventricular mass index (LVMI) irrespective of EF%,
maximum velocity, peak pressure gradient and mean
pressure gradient across the aortic valve and the aortic
valve area. Our study demonstrated that GLS gradually
decreased from an earlier to later stage of AS with
unchanged EF.
Our study is in agreement with a study designed in
Department of Cardiology, and Department of
Cardiovascular Surgery, Juntendo University School of
Medicine, Tokyo, Japan 2011(Sakiko Miyazaki et al.,2011:
703–708) they studied 113 AS patients (age, 63.3 ±8.8)
years; male, 38%; female 62%, aortic valve area (AVA),
1.0 ± 0.3 cm2; mean pressure gradient (PG, 33.8 ±
22.1mmHg) with normal LVEF (≥50%) but without overt
coronary artery disease. Patients were stratified into three
groups (mild, moderate and severe AS), and the clinical
characteristics and echocardiographic findings were
compared among the groups, GLS was measured, the
results of this study are that the LVEF was not significantly
different among the three groups. However, GLS showed
significant differences in GLS among the three groups
(mild: 17.1 ± 3.0%, moderate: 16.4 ± 3.0% and severe:
14.5 ± 3.9%, ANOVA P = 0.003). GLS was significantly
correlated with AVA, mean PG& LV mass index denoting
that Despite unchanged LVEF, GLS gradually decreased
as severity of AS increases.
We are in agreement with a larger study(Kusunose K et
al.,2014):938-45) included 395 AS patients (70±14 years,
57% men) with aortic valve area <1.3 cm2 evaluated
between January to June 2008 (excluding severe other
valve disease and LV ejection fraction <50%). AS patients
were classified as (a) moderate–severe (n=93; aortic valve
area, 1.1–1.3 cm2), (b) standard severe (n=161; aortic
valve area, ≤1 cm2; mean gradient ≥40 mm Hg), and (c)
paradoxical severe (n=141; aortic valve area, ≤1 cm2 and
mean gradient <40 mm Hg), and this study results in that
LV-GLS was independent predictor of mortality. LV-GLS
<−12.1% was associated with significantly reduced
survival.
We are also in agreement with even studies focusing on
congenital AS patients (Susan M et al., 2015.07.042) as
that designed in 2015 included 29 patients with congenital
A Speckle Tracking Echocardiographic Study for Correlation Between Global Left Ventricular Strain and Severity of Aortic Stenosis
Int. J. Cardiol. Cardiovasc. Res. 049
AS with a median age of 15.3 years (range 1.7 to 23.7),
highest life time AS peak gradient of 73 mm Hg (22 to 110),
most recent AS peak Doppler gradient of 49 mm Hg (0
to90), and ejection fraction of 65 (55 to 79) were included.
Strain was measured using 2- dimensional speckle-
tracking echocardiography. Cardiac magnetic resonance
was used to identify focal fibrosis by late gadolinium
enhancement (LGE) and diffuse fibrosis by calculating the
extracellular volume fraction (ECV) Compared to age-
matched controls (n [ 29), patients with AS had reduced
LV longitudinal strain (17.0 – 3.0% vs 20.6 – 2.2%, p
<0.001), radial strain (28.8 – 8.6% vs 34.9 – 8.5%, p [
0.01), and similar circumferential strain (26.2 – 5.9% vs
26.4 – 3.9%, p [ 0.79). Median ECV in patients with AS
was 0.27 (0.22 to 0.38) and was not significantly correlated
with systolic strain.
Patients with LGE (n [ 7) had lower longitudinal strain than
those without LGE (n [ 21; 15.0 – 2.2 vs 17.7 – 3.1, p [
0.036). denoting that in children and young adults with
congenital AS and preserved ejection fraction, longitudinal
and radial strain were reduced, and decreased longitudinal
strain was associated with LGE but not ECV. Decreased
left ventricular (LV) global longitudinal strain by 2-
dimensional speckle-tracking echocardiography has been
found in children with congenital AS who have a normal
ejection fraction, but its cause has not been established.
One hypothesis is that pressure overload on the left
ventricle may compromise myocardial perfusion and lead
to ischemia and fibrosis.
Also, in New York 2013 a total of 58 patients with various
degrees of isolated congenital aortic stenosis (CAS) and
52 healthy controls were enrolled in a study. (Vehbi Dogan
et al., 2013) Conventional and two-dimensional speckle
tracking (2DSTE) echocardiography were performed.
Global longitudinal strain (-23.1 ± 3.6 and -23.8 ± 4.7), and
longitudinal strain rate (LSR) (-1.49 ± 0.32 and -1.76 ±
0.39) values were lower as in our study where as
circumferential strain (CS) (-25.9 ± 4.7 and -22.8 ± 6.4) and
circumferential strain rate (CSR) (-1.82 ± 0.46 and -1.69 ±
0.49) values were greater in the patient group than in the
control subjects. The difference was significant for global
LSR and CS (p\0.05) values. Regional analysis showed
lower LS values in the basal part of the left-ventricular free
wall and lower LSR values in the basal parts of both of the
septum and free wall in the patient group (p\0.05). CS
values in the antero septal, posterior, and inferior walls
were significantly greater in the patients (p\0.05).
A study designed in Istanbul in 2013 by Murat Sunbul et
al, included 38 subjects of whom 25 patients with
asymptomatic mild to moderate AS and 13 healthy
controls, this study gave more data as All patients
underwent detailed echocardiographic evaluation at rest
and during supine bicycle exercise test. Left ventricular
functions were evaluated with two-dimensional STE at rest
and during peak exercise, this study resulted in that:
Maklad and Abd El Moneum 050
Conventional echocardiographic parameters were similar
between groups (ejection fraction, pulmonary artery
pressure, heart chamber diameters), But aortic velocity
was significantly higher (2.1 m/s vs 1.3 m/s, p¼0.001) in
the group with AS and the difference increased at peak
exercise (2.7 m/s vs 1.7 m/s, p<0.001). Left ventricular
global longitudinal strain (GLS) was not only significantly
lower in the group with AS (18.6_2.7 vs 21.2_2.8,
p¼0.034) when compared with the control group but also
the difference became more pronounced during peak
exercise (18.1_2.7 vs 23.8_2.3, p<0.001), so GLS is more
sensitive than EF for predicting mortality, particularly in
patients with an EF>50%. If a certain level of GLS predicts
prognosis of asymptomatic AS patients, the assessment of
GLS may provide useful information to identify
asymptomatic AS patients that might benefit from earlier
AVR. Global longitudinal strain measurement by 2DSTE
was superior to EF for the prediction of outcome and may
become the optimal method for assessment of global LV
systolic function. (Carabello BA et al., 2009:956-66)
CONCLUSION
Our study reinforces that LVEF is not a sensitive indicator
for the detection of subclinical systolic dysfunction. STE
seems to prevail over other echocardiographic
approaches in the evaluation of subclinical left ventricular
myocardial abnormalities in AS patients; it appears to be
more sensitive and more independent from various
confounders. Also, Reduction in longitudinal peak systolic
strain assessed using 2D speckle tracking
echocardiography (STE) is an early indicator of subclinical
left ventricular (LV) dysfunction in AS patients. Global LV
strain might provide useful information about the risk of AS
patients. Severity of AS was a predictor for the reduction
of global left ventricular strain which decrease from earlier
to later stage of AS.
RECOMMENDATION
The detection of subclinical cardiovascular complications
in AS patients may provide an approach for identifying high
risk individuals who may benefit from earlier AVR to
prevent such complications. So, it is suggested that all
patients with AS should be routinely and repeatedly
subjected to tissue Doppler and 2D speckle tracking
echocardiography assessment of cardiac functions during
long term management. It is recommended to perform this
study on a larger scale of patients to get more accurate
statistical analysis of the results.
Study limitations
The relatively limited number of the patients could limit the
strength of results and conclusion obtained from this study.
We could not exclude patients who had subclinical CAD
because not all the patients in this study underwent
A Speckle Tracking Echocardiographic Study for Correlation Between Global Left Ventricular Strain and Severity of Aortic Stenosis
coronary angiography. These patients may have different
GLS Compared with patients that have pure AS.
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 Int. J. Cardiol. Cardiovasc. Res. 051

Accepted 18 December, 2017.

Citation: Maklad WA, Abd El moneum MS (2017). A
Speckle Tracking Echocardiographic Study for Correlation
Between Global Left Ventricular Strain and Severity of
Aortic Stenosis. International Journal of Cardiology and
Cardiovascular Research 4(1): 045-051.

Copyright: © 2017. Maklad and Abd El Moneum. This is

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A Speckle Tracking Echocardiographic Study for Correlation Between Global Left Ventricular Strain and Severity of Aortic Stenosis