International Journal of Cardiology 178 (2015) 203–209

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Review

Left ventricular response to pressure afterload in children: Aortic stenosis and coarctation A systematic review of the current evidence Haki Jashari a, Annika Rydberg b, Pranvera Ibrahimi a, Gani Bajraktari a, Michael Y. Henein a,⁎ a b

Department of Public Health and Clinical Medicine, Umeå University, Sweden Department of Clinical Sciences, Umeå University, Sweden

a r t i c l e

i n f o

Article history: Received 26 July 2014 Received in revised form 10 October 2014 Accepted 18 October 2014 Available online 22 October 2014 Keywords: Congenital aortic stenosis Coarctation of aorta Left ventricle Myocardial deformation imaging

a b s t r a c t Congenital aortic stenosis (CAS) and Coarctation of Aorta (CoA) represent two forms of pressure afterload that affect the left ventricle (LV), hence require regular echocardiographic monitoring. Subclinical dysfunction of the LV exists even in asymptomatic patients with preserved left ventricular ejection fraction (EF), implying low sensitivity of EF in predicting optimum time for intervention. In this article we review patterns of LV myocardial deformation before and after correction of CAS and CoA in infants, children and adolescents, showing their important role in monitoring the course of LV dysfunction. A systematic search using PubMed was performed and suitable studies are presented on a narrative form. Normal EF and/or fractional shortening (FS), with subclinical myocardial dysfunction are reported in all studies before intervention. The short-term results, after intervention, were related to the type of procedure, with no improvement or further deterioration related to surgery but immediate improvement after balloon intervention. Long term follow-up showed further improvement but still subnormal function. Thus correction of CAS and CoA before irreversible LV dysfunction is vital, and requires longitudinal studies in order to identify the most accurate parameter for function prognostication. Until then, conventional echocardiographic parameters together with myocardial velocities and deformation parameters should continue to provide follow-up reproducible measures of ventricular function. © 2014 Elsevier Ireland Ltd. All rights reserved.

1. Background Congenital aortic stenosis (CAS) and aortic coarctation (CoA) represent two forms of pressure afterload on the left ventricle (LV) due to stenotic valves and/or narrowed aortic root/proximal descending aorta and hence increased backward pressure. Aortic tubal narrowing/obstruction can be isolated or at multiple levels, often in combination with septal defects or conotruncal anomalies, resulting in different forms and severities of pressure and volume LV overload [1]. Congenital AS is commonly (70%) caused by abnormal aortic valve leaflets, although obstruction may affect the subvalvular area (14%) or supravalvular region (8%) or rarely more than one level concomitantly (8%) [2]. The incidence of CAS is 401/million live births, with a clear male predominance 4:1 [3,4]. The commonest leaflet anomaly causing AS is the bicuspid aortic valve disease (BAV), commonly detected in children and adolescents. Unicuspid AS is more frequently seen in neonates presenting with critical AS, and it often requires urgent ⁎ Corresponding author at: Heart Centre and Public Health and Clinical Medicine, Umeå University, Umeå, Sweden. E-mail address: [email protected] (M.Y. Henein).

http://dx.doi.org/10.1016/j.ijcard.2014.10.089 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.

intervention [5]. The incidence of BAV in the general population is approximately 1–2%, with a male predominance of 2:1 [6,7]. AS caused by BAV syndrome may develop at any age, since the leaflet anomaly makes it prone to calcification and fibrosis, hence, most patients show signs of calcification by the age of 30 years [8]. Discrete coarctation of the aorta consists of short-segment narrowing in the region of the ligamentum arteriosum adjacent to the origin of the left subclavian artery, which may rarely involve the aortic arch or isthmus. Extensive collateral vessels may develop proximal to the obstruction, which may reduce the pressure drop across the CoA and mask the severity of the obstruction. CoA affects 409/million live births with a modest male predominance of 1.5:1 [1,3]. Concomitant aortic lesions with CoA are common, mostly BAV in approximately 50–75% of patients [9]. Aortic obstructive lesions are currently considered not simple anomalies but a genetic disorder of the cardiac and aortic development [10–14]. An autosomal dominant pattern of inheritance has been suggested [15–17]. The 9% prevalence of BAV in first-degree relatives of patients supports the current guidelines of the American College of Cardiology/American Heart Association which recommend echocardiographic family screening [18]. This is further supported by the evidence

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that considers LV outflow tract and aortic obstructive lesions as intrinsic anomalies of the vascular system, associated with an increase in collagen and decrease of smooth muscle content of the aortic segments proximal to the CoA [12,19] as well as the 53% BAV and 32% of their first degree relatives are likely to develop aortic dilatation [20]. Conventional Doppler echocardiographic techniques are the most commonly used investigations for diagnosing and assessing congenital AS and CoA as well as their effect on the left ventricle. Although ejection fraction has been frequently used to reflect LV systolic function, it is unable to detect associated subclinical function disturbances, particularly at the subendocardial level, commonly seen in pressure afterload pathology, even before obvious myocardial hypertrophy develops [21–24]. Recently MRI has become an attractive non-invasive tool for assessing heart anomalies including congenital AS and CoA but it is known for its limited availability, need for sedation as well as the need for special expertise. 2. Objectives The objective of this review is to assess LV function changes in infants, children and adolescents with CAS or CoA using various recent echocardiographic modalities including myocardial deformation imaging techniques as well as comparing LV function parameters between pre- and post-intervention among studies. 3. Search engine and evidence criteria Between July 2014 and August 2014, a systematic search using PubMed for studies reporting LV function in congenital AS and CoA in infants, children and adolescents was performed. Additional studies were identified by a manual search of references. No language or year of publication restriction was applied. Search terms included “aortic stenosis”, “valvular stenosis”, aortic coarctation, left ventricular, “left ventricular dysfunction”, “left ventricular function”, infants, children, adolescents, pediatric, “two dimensional speckle tracking echocardiography”, “tissue Doppler imaging”, “left ventricular twist”, “left ventricular rotation”, “left ventricular torsion”, “left ventricular strain”, “strain of the left ventricle”, “torsion of the left ventricle”, “twist of the left ventricle” and “rotation of the left ventricle”. 3.1. Inclusion and exclusion criteria We included studies published between 2006 and 2013. Two researchers (HJ, PI) independently reviewed titles and abstracts of the search results, including only studies that compared post-intervention to pre-intervention LV function in infants, children and adolescents with congenital AS and/or CoA. Editorials, review articles and case reports were excluded. Full text articles were then retrieved and reviewed. Reference lists of the retrieved articles were searched manually for potentially relevant articles.

function into, pre-intervention, early post-intervention (up to 6 months) and late post-intervention (beyond 6 months). 4. Qualified studies The PubMed search identified 4945 articles. After a review of titles and abstracts we identified 136 papers reporting LV function in congenital AS and CoA in the pediatric population. Having critically reviewed the full text, only 7 papers proved suitable for inclusion in this review (Fig. 1 and Table 1). Four, one and two studies reported on congenital AS [25–28], CoA [29] and combined diseases [30,31], respectively. Three studies reported on LV function pre-, early post- and late post-intervention intervals [26,28,31]. Two studies reported LV function only on pre- and early post-intervention [25,30], while the remaining two studies reported only on pre- and late post-intervention LV function [27,29]. Four studies evaluated LV function with TDI [25,27–29], three of them used GE EchoPAC [25,28,29] as offline analysis software, and in the forth study the TDI analysis tool was not reported [27]. Offline speckle-tracking analysis was performed using GE EchoPAC software in three studies [26,30,31]. The total number of studied patients was 199, 123 with CAS and 76 with CoA. Four studies included a total number of 188 healthy controls. All studies reported normal LV systolic function in the form of EF and/or fractional shortening (FS) pre-intervention. 4.1. Aortic stenosis Patients with CAS requiring intervention had already clear evidence for left ventricular long axis dysfunction before intervention [26,30,31] while EF and/or FS were within normal ranges. Marcus et al. [26] reported simultaneously reduced circumferential and radial strain/strain rate parameters together with suppressed longitudinal function. However, Laser et al. [30] reported an accentuated circumferential function as well as enhanced torsion preoperatively as potential compensatory mechanisms to the disturbed longitudinal function. The short-term effect of CAS repair seems to be dependent on the type of intervention used. Balloon aortic valvuloplasty (BAVP) resulted in significant improvement of LV function within hours [30] or days [25] compared to pre-intervention but still was subnormal six months post-BAVP [26]. On the other hand surgically treated patients had no improvement of global strain [28] but rather further deterioration of longitudinal strain [31] a few weeks after surgery. Long-term improvement of global [28] and longitudinal strain [31], despite remaining subnormal, has been reported. Likewise, Marcus et al. [26] noticed significant improvement of longitudinal, radial and circumferential strain/strain rate, which still remained subnormal, despite the normalization of radial function. LV diastolic function has also been found to be abnormal in CAS patients, and is influenced by intervention. While balloon aortic valvuloplasty leads to short [25] and long term [27] improvement of LV diastolic function, Mi et al. [28] reported non-significant improvement 12 months after surgical aortic valve replacement (AVR).

3.2. Data extraction One reviewer extracted the data and summarized the findings of the studies. Predetermined data of interest were the first author, year of publication, title, journal, study population, age of population at time of intervention, type of intervention, duration of follow-up, presence or absence of a control group, method of LV function evaluation and LV function parameters. 3.3. Data synthesis Statistical meta-analysis of the results was unsuitable due to the different methodologies used in individual studies. However, we decided to present the results in a narrative form, dividing parameters of LV

4.2. Coarctation of Aorta LV systolic dysfunction, in terms of myocardial deformation parameters, has been reported in patients with CoA prior to intervention [29–31]. LV longitudinal strain has been found decreased but to a lesser extent compared to CAS [30,31], with the circumferential strain/strain rate and torsion being higher than in CAS [30]. As is the case with CAS, short-term LV response to intervention was dependent on the procedure used. LV maximum torsion reduced soon (4–6 h) after balloon aortoplasty, despite the need for additional stenting in almost two thirds of patients [30]. In contrast, Van der Ende et al. [31] reported further longitudinal strain reduction, one week post-intervention irrespective of procedure.

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Fig. 1. Paper selection flowchart. CHDs — congenital heart diseases.

In general, LV deformation parameters improved at long-term postintervention, despite remaining subnormal [29,31]. Importantly, the effect of age at intervention seems to influence the rate of LV function recovery. Using TDI, Klitsie et al. [29] reported persisting LV systolic dysfunction after intervention, in neonates, while non-neonates recovered to normal, may be because neonates usually present with a more severe coarctation leading to circulatory problems. Changes in LV diastolic function has also been studied in CoA, and showed significant impairment pre-correction [29]. While short-term effect of procedure has not been reported, diastolic function has been shown to improve long-term post-correction of CoA but still remaining subnormal [29].

translated into compromised diastolic myocardial perfusion time [45, 46]. The turbulent aortic flow beyond the aortic valve in AS has also been shown to disturb normal coronary flow [44]. Finally, long standing diastolic myocardial disturbances, themselves, will eventually increase cavity stiffness and raise end-diastolic pressure which itself affects subendocardial perfusion and function (Fig. 2). These pathophysiologic changes vary in their manifestation, from being subclinical into clear signs and symptoms of heart failure with normal or preserved EF (HFpEF). Despite that, studies have already shown that segmental intrinsic myocardial function of HFpEF patients is abnormal, particularly velocities and deformation function. 5.2. Effect of ischemia and fibrosis on LV function

5. Data interpretation 5.1. Pathophysiology Children born with congenital AS and CoA suffer from LV pressure overload, and the cavity wall becomes hypertrophied to compensate for the increased wall stress and to maintain ejection function. Later, the deleterious effects of hypertrophy and associated myocardial fibrosis become apparent, with the development of systolic and diastolic dysfunction [22,25,32–37]. It must be mentioned that myocardial response to pressure overload is age-dependent [38]. Children's myocardium has the ability to regenerate and develop more vascularity, which maintain subendocardial blood supply and hence delay the development of overt dysfunction and heart failure for a long time [39–41]. Despite such degree of compensation, histological examinations of congenital AS and CoA autopsies reported higher degrees of fibrosis in the subendocardial layer compared to mid-wall and subepicardial layer of the LV [42], suggesting persistent compromised coronary flow reserve with its drastic effect [43]. Another potential explanation for subendocardial disturbances is aortic reflected waves which normally augment diastolic pressure and increase diastolic perfusion of the subendocardium, but with increased pressure afterload and aortic stiffness [44], the reflected waves become systolic in time and hence compromised diastolic coronary pressure with its consequences. A third explanation is the short diastole in patients with pressure afterload due to prolonged systole, which is

The subendocardial myocardial layer is made of longitudinal fibers that originate at the LV apex and insert around the circumference of the mitral annulus. LV long axis ‘subendocardial function’ has already been shown to be abnormal [30,31] in congenital AS and CoA despite preserved radial function and overall EF, suggesting that the latter are interrelated [23]. Various mechanisms compensating for the disturbed long axis function in congenital AS and CoA have been proposed including increased circumferential strain/strain rate and torsion, in patients with respectively decreased longitudinal strain and strain rate [30] (Fig. 3). The subendocardial ischemia in these patients reduces its opposing function to the subepicardial forces thus, increasing torsion [30]. This interaction between myocardial layers has been shown by different echocardiographic techniques [47,48]. However, Marcus et al. [26] have shown decreased deformation parameters in all three directions. It is important to mention that abnormal torsion and longitudinal function can be provoked by exercise at much earlier stage of disease, at which time diastolic untwisting during isovolumic relaxation can also be reduced and delayed [49]. Association of deformation parameters with severity of CAS [26,28] suggests its superior predictive value compared with other LV function parameters. However, others failed to show such a relation in congenital AS and CoA patients due to high variability of pressure gradients [30] or small and heterogeneous number of patients [25]. Although congenital AS and CoA are two forms of LV pressure afterload, the extent of their individual effect on the cavity function

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Table 1 Studies included in the review article. Follow-up duration

CHD (Nr.)

Compare group

Intervention method

Evaluation Age (mean)/ method intervention agea

De Kort [25]

CAS (9)

Preintervention

BAVP

TDI

Laser [30]

CAS (10) CoA (27)

37 healthy controls

2DSTE

Marcus [26]

CAS (37)

74 healthy controls and 76 uncorrected CAS Preintervention

CAS: BAVP CoA: BD + 19 additional stenting BAVP

2DSTE

0–15.5 (6.7) years

3 years

BAVP

TDI

3.2–40.1 (11.5) years a

6–24 (11) months

Friedman CAS (25) [27] Van der Ende [31]

CAS (21)

Klitsie [29]

CoA (37) (NN—18; nonNN— 19) CAS (21) AR (11)

Mi Yb [28]

40 healthy controls

CoA (12)

37 (18 + 19) healthy controls Preintervention

CAS: 11 2DSTE surgery CoA: 2 surgery &3 catheterization Mostly EEA TDI

AVR

TDI

1 month– 1–4 days 14 years (1 year) 11.9 ± 5.9 years 4–6 h

10.1 ± 4.6 years 42 weeks

Pre-intervention

Short-term post-intervention (time postintervention)

No control group

Systolic and diastolic improvement (Systolic and diastolic tissue velocities increased)

LV dysfunction (TORmax and circumferential S/SR increased; longitudinal S/SR decreased; radial S/SR similar) Global peak S/SR decreased in all 3 directions

Improvement but still subnormal LV function (TORmax decreased; longitudinal S/SR–NS changes; circumferential S/SR partially decreased; radial S/SR partially increased). S/SR increased in all 3 directions, but still subnormal Improvement but still subnormal. (6 months) longitudinal and circumferential S/SR lower but radial S/SR similar to control groups

No control group

Longitudinal S decreased

NN-15 days; nonNN131 days a

11.4 ± 8.3 months Systolic and diastolic dysfunction (decreased systolic and diastolic tissue velocities)

11.5 ± 4.7 years; 0.3-−18 (12.6) years a

12 months

No control group

Longitudinal S continued to decrease (1 week)

Long-term post-intervention

Diastolic function improvement (early diastolic tissue velocity increased) Longitudinal S increased but still subnormal

Both groups — diastolic dysfunction; only NN — systolic dysfunction NS improvement (2 weeks)

Global peak S increased; myocardial velocities and SR–NS changes

CHD — congenital heart disease; CAS — congenital aortic stenosis; CoA — Coarctation of Aorta; AR — aortic regurgitation; BAVP — balloon aortic valvuloplasty; BD — balloon dilatation; EEA — end to end anastomosis; AVR — aortic valve replacement; NN — neonatal; nonNN — non neonatal; TDI — tissue Doppler imaging; 2DSTE — two-dimensional speckle-tracking echocardiography; S — strain; SR — strain rate; S/SR — strain/strain rate; TORmax — maximal torsion; NS — non-significant. a Intervention age b Only CAS patients were analyzed.

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Study

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Fig. 2. Pathophysiology of subendocardial hypoperfusion — algorithm. CAS/CoA — Congenital aortic stenosis/Coarctation of Aorta; LVH — left ventricular hypertrophy; LVEDP — left ventricular end diastolic pressure.

differs. In adults, Lam et al. [22] showed less LV function impairment with CoA compared to AS, claiming that the distance of narrowing/obstruction is a contributing factor as well as the role of collaterals. Complementary findings were reported by Laser et al. [30] and Van der Ende et al. [31] showing higher values of torsion and lower long axis function respectively, in CAS compared to CoA in children. It seems that such differences are related to the changes that those condition cause at the myocardial level with less fibrosis in CoA compared to CAS [42]. Four more studies reporting on LV function that is CAS prior to intervention were not included in this review article due to the absence of followup data. However, most of them fall in agreement with the included studies. Kiraly et al. [37] present the earliest TDI study in the field (2003) reporting subnormal systolic and early diastolic function while late diastolic function of the LV was normal. Leonardi et al. [47] through TDI and Dogan et al. [48] through 2DSTE found decreased longitudinal function while increased circumferential function together with twist and circumferential function respectively, was reported. These findings provide more evidence for theory of longitudinal dysfunction compensation (Fig. 3). Otherwise, Marcus et al. [50] on another 2DSTE study reported similar results with the included study of the

Fig. 3. Most widely accepted compensation/decompensation pattern for longitudinal dysfunction.

same authors [26], finding decreased deformation parameters in all three directions prior to intervention. 5.3. Effect of removal of pressure afterload on LV Correction of congenital AS and CoA results in overall improvement of LV function, at short term, depending on the type of intervention. While balloon intervention with/without additional stenting results in almost immediate improvement of function [30], surgical intervention may be associated with a delayed recovery probably due to the need for bypass circulation (in AS) with its known complications, previously shown in adults [51]. Within 4–6 h of balloon intervention, LV torsion improves making it a sensitive marker of early response to removal of pressure afterload. However, studies have shown that despite early recovery of LV function, systolic and diastolic function remain subnormal, suggesting that the intervention corrects the functional component of the abnormalities while leaving the disturbances related to the more organized pathology i.e. myocardial fibrosis. Four studies used TDI to compare LV function long term post-CoA intervention with controls, they did not report pre-intervention values therefore did not fulfill the criteria of inclusion. di Salvo et al. [52] reported subnormal longitudinal and supernormal radial strain rate, years after intervention. Likewise, Lombardi et al. [53] reported decreased systolic and early diastolic function, with the former being non-significant. Contrary to these, Florianczyk and Werner have shown supernormal systolic function [54] and decreased early diastolic with increased late diastolic function [55], respectively, nearly a decade after CoA surgery. Despite the impact of small number of patients and age discrepancy among studies, inconsistencies regarding the response of radial and circumferential function to intervention, could be further explained on the basis of limited reproducibility of the measurements used. This explanation was further confirmed by comparing results obtained from different echocardiographic systems, as has been recently shown both in children [56] and adults [57]. It seems that the most robust measurement of myocardial function is longitudinal strain, irrespective of the way data is stored [56,57]. The reproducibility of circumferential strain has been shown to be only moderate with that of the radial and transverse strain being the poorest, particularly when using 2D-STE velocities [57,58]. The resulting confusion therefore urges the need for standard measurement values for various segmental and global myocardial function parameters.

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6. Limitations Our study has some limitations that may influence the review results presented. First, most of the studies included small number of patients. Age discrepancy among studies is another limiting problem. Finally, different methods of evaluating LV function are another limitation. However, since patients were compared with themselves, the change of function should be taken as a procedure related effect, irrespective of the technique used for assessing LV function.

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Left ventricular response to pressure afterload in children: aortic stenosis and coarctation: a systematic review of the current evidence.

Congenital aortic stenosis (CAS) and Coarctation of Aorta (CoA) represent two forms of pressure afterload that affect the left ventricle (LV), hence r...
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