Usefulness of Aortic Strain Analysis by Velocity Vector Imaging as a New Echocardiographic Measure of Arterial Stiffness

doi:10.1016/j.echo.2009.08.024

Journal of the American Society of Echocardiography

Volume 22, Issue 12, December 2009, Pages 1382-1388

https://doi.org/10.1016/j.echo.2009.08.024 Get rights and content

Background

The role of velocity vector imaging (VVI) in evaluating arterial stiffness is not well known. We investigated the usefulness of vascular strain analysis by VVI in evaluating arterial stiffness.

Methods

Heart-femoral and brachial-ankle pulse wave velocities (PWVs) were measured as standard parameters of arterial stiffness. Intima–media thickness (IMT), fractional shortening (FS), fractional area change (FAC) by two-dimensional (2D) and VVI methods, and peak circumferential strain (PS) of the descending thoracic aorta were measured as echocardiographic parameters of arterial stiffness and compared with PWV in 137 patients (53.8 ± 13.4 years, 71 male).

Results

Heart-femoral PWV was 9.0 ± 2.4 m/s, and brachial-ankle PWV was 14.1 ± 3.0 m/s. Aortic IMT was 0.97 ± 0.23 mm, and FS was 10.0% ± 4.0%. FAC was 10.9% ± 5.2% by 2D tracing and 10.3% ± 5.1% by the VVI method. PS was 5.4% ± 3.0%. PS showed significant negative correlation with aortic IMT (r = −0.49, P < .01) and PWV (heart-femoral: r = −0.67, brachial-ankle: r = −0.75, P < .01). PS showed significant positive correlation with FS (r = 0.80, P < .01) and FAC (2D tracing: r = 0.86, VVI: r = 0.88, P < .01). Aortic IMT showed significant positive correlation with PWV (heart-femoral: r = 0.44, brachial-ankle: r = 0.60, P < .01) and negative correlation with FS (r = −0.61, P < .01) and FAC (2D tracing: r = −0.51, VVI: r = − 0.51, P < .01). FS showed significant negative correlation with PWV (heart-femoral: r = −0.54, brachial-ankle: r = −0.72, P < .01). FAC showed significant negative correlation with heart-femoral (2D method: r = −0.61, VVI: r = −0.62, P < .01) and brachial-ankle (2D tracing: r = −0.71, VVI: r = −0.73, P < .01) PWV.

Conclusion

PS and FAC measured by VVI were significantly associated with parameters of arterial stiffness and thus can be used as new echocardiographic parameters of arterial stiffness.

Section snippets

Study Population

The study protocol was approved by the Institutional Review Board of Chonnam National University Hospital, and informed consent was obtained from each patient. From January 2006 to June 2007, transesophageal echocardiography (TEE) was performed in 286 patients at the Chonnam National University Hospital. Among them, 149 patients were excluded for the following reasons: atrial fibrillation or flutter in 57 patients, significant aortic valvular disease in 26 patients, known heart failure or

Characteristics of the Patients

The baseline characteristics of patients are summarized in Table 1. There was a slight male predominance, and hypertension was the most prevalent cardiovascular risk factor.

Measurements of the TEE Parameters

The results of the TEE parameters are summarized in Table 2. PS showed a significant negative correlation with aortic IMT (r = −0.49, P < .01) and a positive correlation with FS (r = 0.80, P < .01) and FAC (2D tracing: r = 0.86, VVI: r = 0.88, P < .01) (Figure 3). Aortic IMT showed a significant positive correlation with PWV

Discussion

The present study demonstrated that PS and FAC can be easily measured by the VVI technique, and that these values were significantly associated with the parameters of arterial stiffness measured by PWV. Therefore, the present study suggested that the novel VVI technique is a useful method in evaluating not only cardiac mechanics but also vascular mechanics. To the best of our knowledge, the present study is the first attempt to use the novel VVI technique for the evaluation of arterial wall

Conclusions

Despite some limitations, the present study demonstrated that PS and FAC can be easily measured by the VVI technique, and that both were significantly associated with the parameters of arterial stiffness. Therefore, vascular strain analysis by VVI can be used as a new echocardiographic parameter of arterial stiffness.

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After AVR for AI and AS, the direction of change in distal aortic strain from baseline depends on valve pathology. This finding may have important clinical implications in terms of indication for surgery and postoperative surveillance, especially in patients with aortopathies.
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Two-dimensional speckle-tracking echocardiography (STE) allows for identifying speckles in ultrasound grayscale images and tracking their movement. It is already widely used for assessing the mechanics of the myocardium (Collier et al., 2017) (Voigt et al., 2015) and also of elastic properties of large vessels, like the aorta (Kim et al., 2009) or carotid arteries (Yuda et al., 2011). The aim of our study was to investigate whether STE may prove useful in quantifying the degree of deformation of calcified AV leaflets.
Calcific aortic valve (AV) disease is associated with increased stiffness and reduced motion of AV leaflets, has a progressive course, and can develop into aortic stenosis (AS). Our aim was to evaluate whether two-dimensional speckle-tracking echocardiography (STE) may be used for the assessment of AV stiffness. We applied STE to AV leaflets in patients with various degrees of degenerative changes of AV and measured strain as an absolute value of the radial deformation of AV leaflets. Deformation of AV expressed as averaged AV strain was greatest in patients with a normal AV (23.4 ± 6.4%), compared to those with aortic sclerosis (12.9 ± 3.2%), moderate-to-severe AS (11.9 ± 4%), and severe AS (10.9 ± 3.5%) (p < 0.01). A non-linear relationship and moderate correlation of AV strain with transvalvular hemodynamic parameters was observed. In patients with mild-to-moderate AS, the strain of AV leaflets also correlated negatively with AV calcification (r = −0.59, p = 0.008). Good inter-observer agreement was obtained for averaged AV strain with a coefficient of variation of 0.15 and an interclass correlation coefficient of 0.94 (p < 0.0001). In this study we demonstrated that deformation of AV leaflets as assessed by STE might be a potential method for a non-invasive evaluation of AV biomechanical properties and of the progression of calcific aortic disease. Further development of the two-dimensional speckle tracking technique specifically for valve structures is needed to enable a better quantification of leaflet deformation.
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Consistent with this concept, the group employed cine cardiac magnetic resonance imaging to demonstrate decreased distensibility of the descending aorta among patients with Marfan syndrome vs. normative controls (p < .001), paralleling a similar trend when Marfan patients were compared with those with bicuspid aortic valve (p = .09).26 Prior studies have employed echo to assess vascular stiffness in the descending and abdominal aorta.18,26–28 For example, among a cohort of hypertensive patients, echo derived circumferential strain has been shown to be impaired compared with controls.29
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Forty-five patients undergoing AA replacement with prosthetic graft (91% elective) were studied. Following grafting, descending thoracic aortic circumferential strain increased (6.3 ± 2.8% vs. 8.9 ± 3.4%, p = .001) paralleling distensibility (5.7 [3.7–8.6] 10⁻³ mmHg vs. 8.5 [6.4–12.4] 10⁻³ mmHg, p < .001). Despite slight increments in post graft left ventricular ejection fraction (LVEF) (52.3 ± 10.8% vs. 55.0 ± 11.9, p < .001), stroke volume was similar (p = .41), and magnitude of increased strain did not correlate with change in stroke volume (r = −.03, p = .86), LVEF (r = .18, p = .28), or pulse pressure (r = .28, p = .06). Descending aortic size (EDA 4 [2.7–4.6] cm² vs. 3.7 [2.5–5] cm², p = .89; ESA 4.3 [3.2–5.3] cm² vs. 4.5 [3.3–5.8] cm², p = .14) was similar pre- and post graft. In subgroup analysis, patients with cystic medial necrosis had a significantly higher post procedure CAS than patients with atherosclerotic aneurysms (9.7 ± 3.5% vs. 7.0 ± 2.3%, p = .03).
Prosthetic graft replacement of the AA increases immediate aortic circumferential strain of the descending aorta, particularly in patients with cystic medial necrosis. Our findings suggest that grafts augment energy transfer to the distal aorta, a potential mechanism for progressive distal aortic dilation and/or dissection.
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Imaging studies based on new cutting-edge technologies, such us 4-dimensional (4D) flow magnetic resonance imaging (MRI), two-dimensional (2D) or three-dimensional (3D) speckle-tracking imaging (STI) and computation fluid dynamics, combined with studies demonstrating new gene mutations, specific signal pathways alterations, hemodynamic influences, circulating biomarkers modifications, endothelial progenitor cell impairment and immune/inflammatory response, all detected BAV valvulopathy progression and aortic wall abnormality.
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Clinical InvestigationVascular DiseaseUsefulness of Aortic Strain Analysis by Velocity Vector Imaging as a New Echocardiographic Measure of Arterial Stiffness

Background

Methods

Results

Conclusion

Section snippets

Study Population

Characteristics of the Patients

Measurements of the TEE Parameters

Discussion

Conclusions

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Am J Cardiol

Am J Cardiol

J Am Soc Echocardiogr

Atherosclerosis

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

Arterial stiffness: pathophysiology and clinical impact

Clin Exp Hypertens

Arterial stiffness, wave reflections, and the risk of coronary artery disease

Circulation

Mechanisms, pathophysiology, and therapy of arterial stiffness

Arterioscler Thromb Vasc Biol

Noninvasive assessment of arterial stiffness and risk of atherosclerotic events

Arterioscler Thromb Vasc Biol

Clinical Investigation
Vascular Disease
Usefulness of Aortic Strain Analysis by Velocity Vector Imaging as a New Echocardiographic Measure of Arterial Stiffness