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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Over the last decade&#44; research into left ventricular &#40;LV&#41; structure and function in patients with aortic stenosis &#40;AS&#41; has increased&#44; due to improvements in imaging modalities and potential therapies&#46; This has prompted a focus on subclinical changes in LV function&#44; as well as the degree of reversibility of LV structural changes in advanced stages of AS&#46; These factors may influence the optimal timing of valve intervention&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of the Portuguese Cardiology Journal&#44; Azevedo et al&#46; sought to compare cardiac magnetic resonance &#40;CMR&#41; assessed global radial strain &#40;GRS&#41;&#44; global circumferential strain &#40;GCS&#41;&#44; and global longitudinal strain &#40;GLS&#41; in AS patients with preserved LVEF before and after aortic valve replacement and to explore its clinical utility for detecting LV systolic function changes in LV reverse remodeling&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Assessing the consequence of aortic stenosis for the left ventricle</span><p id="par0015" class="elsevierStylePara elsevierViewall">The magnitude of LV hypertrophy &#40;LVH&#41; is poorly linked to AS severity&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> suggesting that other factors are also involved in its development&#46; Age&#44; gender&#44; angiotensin-converting enzyme I&#47;D polymorphism&#44; co-existing coronary artery disease and hypertension are additional factors influencing LV response to AS&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> Histopathological studies have shown that myocardial fibrosis in particular is an integral part of myocardial disease progression in AS&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> The mechanisms governing the development and progression of myocardial fibrosis &#40;MF&#41; are not fully understood&#46; Myocardial fibrosis has traditionally been categorized as diffuse interstitial fibrosis &#40;appears to be reversible with afterload relief&#41; or replacement fibrosis &#40;myocyte necrosis&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">LV remodeling characterization</span><p id="par0020" class="elsevierStylePara elsevierViewall">Echocardiography is the first line and the most commonly used imaging technique to assess patients with AS&#46; Linear LV dimensions must be measured to calculate the LV mass and LV mass index for LV remodeling classification&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> however it has several limitations relative to CMR &#40;poor acoustic windows&#44; misaligned LVs&#44; difficulties in delineating the posterior wall&#44; inaccurate estimation of the LV mass in the presence of asymmetrical hypertrophy&#44; etc&#46;&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Certain remodeling patterns are associated with a worse outcome&#44; and there may be sexual dimorphism in the myocardial response to AS&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Left ventricular fibrosis&#44; left ventricular diastolic and systolic function</span><p id="par0030" class="elsevierStylePara elsevierViewall">Left ventricular fibrosis in AS was first described in histopathologic studies as part of the hypertrophic response&#58; increasing myocyte size eventually leads to myocyte apoptosis and subsequent replacement fibrosis&#44; possibly explaining the transition from hypertrophy to heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> In AS&#44; MF&#44; defined as a significant increase in the collagen volume fraction of myocardial tissue&#44; is a complex process involving at least three main alterations&#58; endocardial thickening&#44; subendocardial microscars&#44; and diffuse interstitial fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Although myocardial biopsy is the gold standard to diagnose MF&#44; it is invasive and has some limitations &#40;mainly sampling errors and the inability to assess MF globally&#41;&#46; Cardiac magnetic resonance is the only non-invasive alternative that enables direct global assessment of MF&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> using two approaches&#58; late gadolinium enhancement &#40;LGE&#41; and myocardial T1 mapping&#46; LGE enables the quantification of focal interstitial expansion&#44; with direct visualization of focal replacement fibrosis&#44; whereas myocardial T1 mapping assesses the diffuse interstitial expansion of fibrosis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Replacement fibrosis is detected with CMR using LGE<span class="elsevierStyleBold">&#46;</span> Beta gadolinium-based contrast agents partition into extracellular space and wash out of areas of focal fibrosis slower than healthy tissue&#46; Multiple studies have consistently shown strong independent associations between ischemic and non-ischemic LGE and both cardiovascular and all-cause mortality&#46; Furthermore&#44; the development of non-ischemic LGE in AS appears to serve as an objective marker of LV decompensation and portends further rapid progression of fibrosis burden&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> Importantly&#44; this fibrosis does not regress after aortic valve replacement &#40;AVR&#41;&#59;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8&#44;10</span></a> the burden of scarring that develops while awaiting surgery persists in patients for life&#46; This is important because the greater the MF&#44; the worse the long-term prognosis is&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The detection of LGE in AS may therefore offer incremental prognostic information&#46; Clinical implementation of LGE to optimize the timing of aortic valve intervention is being tested in the randomized EVOLVED-AS trial &#40;Early Valve Replacement Guided by Biomarkers of LV Decompensation in Asymptomatic Patients with Severe AS&#44; Clinical Trials&#46;gov 03094143&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Unlike LGE&#44; which is insensitive for the detection of diffuse interstitial fibrosis&#44; T1 mapping techniques can provide overall assessments of the extracellular compartment&#46; While providing a close surrogate assessment of myocardial fibrosis&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> these markers are also affected by other extracellular factors including edema and capillary volume&#46; The most studied methods are native T1&#44; which does not require gadolinium contrast&#44; and extracellular volume fraction &#40;ECV&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> T1 mapping has provided important insight into the myocardium in AS&#44; most notably the potential for diffuse fibrosis to reverse post-AVR&#44; with an increasing body of evidence demonstrating its prognostic power in AS with other conditions &#40;cardiomyopathies&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">LV diastolic function is one of the earliest consequences of LVH and MF in AS&#46; LV diastolic dysfunction is associated with increased mortality&#44; worsens with progressive myocardial remodeling before AVR&#44; and gradually improves with reverse remodeling after AVR&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The improvement in diastolic dysfunction in AS takes longer than the reversal of LV systolic dysfunction &#40;the former is mainly related to longstanding LV structural changes while the latter also reflects afterload mismatch&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Although LVEF provides important information and guides therapy&#44; it is load-dependent and not an index of myocardial contractility&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Global longitudinal strain assessment of LV deformation detects earlier changes in myocardial function and enables a better understanding of progression to heart failure in AS&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> Speckle-tracking echocardiography allows for a multidirectional assessment of myocardial deformation&#46; In AS&#44; LV longitudinal strain is impaired&#44; especially in the basal segments&#44; and is a predictor of clinical events in asymptomatic AS &#40;the primary mechanism involved in the alteration of LV longitudinal strain in AS is LV fibrosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Moreover&#44; GLS also depends on the pattern of LV remodeling&#44; with lower values in patients with significant concentric LVH&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Recent studies have shown that GLS predicts postoperative LV dysfunction and outcomes better than ejection fraction&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Although this technique has high levels of acceptance and is widely available&#44; it exhibits several inherent limitations such as poor inter-reader reproducibility and need for an appropriate &#8220;acoustic window&#8221;&#46; Cardiac magnetic resonance feature tracking gives us the possibility of deriving deformation parameters from standard cine sequences and thus combine the advantages of both imaging modalities&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> However&#44; comparability between different vendors&#44; imaging modalities and post-processing software needs to be further assessed and proven&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Assessment of left ventricular reverse remodeling - EPICHEART Study</span><p id="par0090" class="elsevierStylePara elsevierViewall">Ideally&#44; surgery should be performed before irreversible changes occur in the myocardium&#46; Indeed&#44; rather than an isolated valve disease&#44; AS is a more global disease&#44; potentially affecting the entire myocardium&#46; Ejection fraction is the only LV parameter currently recommended to guide intervention in asymptomatic patients with AS&#44; with a cut-off value of 50&#37; for referral for AVR&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Future trials to establish clear thresholds and incorporating GLS into decision-making for asymptomatic patients with AS will be needed to establish its role as a marker of subclinical LV decompensation&#46; The traditional criteria for AVR are now being questioned based on our current understanding of pre-clinical myocardial disease in asymptomatic AS&#46; Echocardiographic and CMR assessment of myocardial deformation and myocardial fibrosis offer clear prognostic information above and beyond valve hemodynamic and LVEF alone&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Azevedo et al&#46; assessed the relationship between global and regional left ventricular strain&#44; strain rate&#44; displacement and velocity using CMR-FT and LVEF before and after AVR in a prospective cohort of AS patients&#46; One objective of this study was to assess reverse remodeling using CMR with standard functional and innovative deformation parameters in patients after six months of AVR &#40;EPICHEART Study&#41; and assess the prognostic impact&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In this study&#44; they found that there is a significant reduction in GLS and GCS CMR parameters after AVR&#44; with unchanged LVEF compared to baseline&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> The authors reported similar findings in several recent echocardiographic studies as well as some studies recently published with CMR-FT within three months of a successful transcatheter valve replacement &#40;TAVR&#41; in comparison to a healthy control group&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">As it was demonstrated that positive response after AVR &#40;surgical valve replacement or TAVR&#41; could be predicted by analyzing longitudinal strain and velocity&#44; it has been suggested that the assessment of cardiac mechanics could be useful for the right timing of AVR&#46; Nevertheless&#44; the prognostic implication of persistent subtle functional abnormalities after AVR remains poorly investigated and thus unclear&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> A correlation between deformation parameters and outcomes has not as yet been reported&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Randomized trials are needed to determine whether the use of fibrosis imaging biomarkers &#40;LGE&#41;&#44; T1 mapping and GLS can improve outcomes of asymptomatic patients with AS&#46; The EVOLVED-AS study<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> is an ongoing trial that should answer these crucial questions&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Editorial comment
Usefulness of advanced cardiovascular imaging in aortic valve replacement. Ready for prime time?
Utilidade da imagiologia cardiovascular avançada na substituição valvular aórtica. Pronta para o horário nobre
Luís M. Moura
Centro de Investigação em Tecnologias e Serviços de Saúde (CINTESIS), Faculty of Medicine, Department of Medicine, University of Porto, Porto, Portugal
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    "titulo" => "Usefulness of advanced cardiovascular imaging in aortic valve replacement&#46; Ready for prime time&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Over the last decade&#44; research into left ventricular &#40;LV&#41; structure and function in patients with aortic stenosis &#40;AS&#41; has increased&#44; due to improvements in imaging modalities and potential therapies&#46; This has prompted a focus on subclinical changes in LV function&#44; as well as the degree of reversibility of LV structural changes in advanced stages of AS&#46; These factors may influence the optimal timing of valve intervention&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of the Portuguese Cardiology Journal&#44; Azevedo et al&#46; sought to compare cardiac magnetic resonance &#40;CMR&#41; assessed global radial strain &#40;GRS&#41;&#44; global circumferential strain &#40;GCS&#41;&#44; and global longitudinal strain &#40;GLS&#41; in AS patients with preserved LVEF before and after aortic valve replacement and to explore its clinical utility for detecting LV systolic function changes in LV reverse remodeling&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Assessing the consequence of aortic stenosis for the left ventricle</span><p id="par0015" class="elsevierStylePara elsevierViewall">The magnitude of LV hypertrophy &#40;LVH&#41; is poorly linked to AS severity&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> suggesting that other factors are also involved in its development&#46; Age&#44; gender&#44; angiotensin-converting enzyme I&#47;D polymorphism&#44; co-existing coronary artery disease and hypertension are additional factors influencing LV response to AS&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> Histopathological studies have shown that myocardial fibrosis in particular is an integral part of myocardial disease progression in AS&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> The mechanisms governing the development and progression of myocardial fibrosis &#40;MF&#41; are not fully understood&#46; Myocardial fibrosis has traditionally been categorized as diffuse interstitial fibrosis &#40;appears to be reversible with afterload relief&#41; or replacement fibrosis &#40;myocyte necrosis&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">LV remodeling characterization</span><p id="par0020" class="elsevierStylePara elsevierViewall">Echocardiography is the first line and the most commonly used imaging technique to assess patients with AS&#46; Linear LV dimensions must be measured to calculate the LV mass and LV mass index for LV remodeling classification&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> however it has several limitations relative to CMR &#40;poor acoustic windows&#44; misaligned LVs&#44; difficulties in delineating the posterior wall&#44; inaccurate estimation of the LV mass in the presence of asymmetrical hypertrophy&#44; etc&#46;&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Certain remodeling patterns are associated with a worse outcome&#44; and there may be sexual dimorphism in the myocardial response to AS&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Left ventricular fibrosis&#44; left ventricular diastolic and systolic function</span><p id="par0030" class="elsevierStylePara elsevierViewall">Left ventricular fibrosis in AS was first described in histopathologic studies as part of the hypertrophic response&#58; increasing myocyte size eventually leads to myocyte apoptosis and subsequent replacement fibrosis&#44; possibly explaining the transition from hypertrophy to heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> In AS&#44; MF&#44; defined as a significant increase in the collagen volume fraction of myocardial tissue&#44; is a complex process involving at least three main alterations&#58; endocardial thickening&#44; subendocardial microscars&#44; and diffuse interstitial fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Although myocardial biopsy is the gold standard to diagnose MF&#44; it is invasive and has some limitations &#40;mainly sampling errors and the inability to assess MF globally&#41;&#46; Cardiac magnetic resonance is the only non-invasive alternative that enables direct global assessment of MF&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> using two approaches&#58; late gadolinium enhancement &#40;LGE&#41; and myocardial T1 mapping&#46; LGE enables the quantification of focal interstitial expansion&#44; with direct visualization of focal replacement fibrosis&#44; whereas myocardial T1 mapping assesses the diffuse interstitial expansion of fibrosis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Replacement fibrosis is detected with CMR using LGE<span class="elsevierStyleBold">&#46;</span> Beta gadolinium-based contrast agents partition into extracellular space and wash out of areas of focal fibrosis slower than healthy tissue&#46; Multiple studies have consistently shown strong independent associations between ischemic and non-ischemic LGE and both cardiovascular and all-cause mortality&#46; Furthermore&#44; the development of non-ischemic LGE in AS appears to serve as an objective marker of LV decompensation and portends further rapid progression of fibrosis burden&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> Importantly&#44; this fibrosis does not regress after aortic valve replacement &#40;AVR&#41;&#59;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8&#44;10</span></a> the burden of scarring that develops while awaiting surgery persists in patients for life&#46; This is important because the greater the MF&#44; the worse the long-term prognosis is&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The detection of LGE in AS may therefore offer incremental prognostic information&#46; Clinical implementation of LGE to optimize the timing of aortic valve intervention is being tested in the randomized EVOLVED-AS trial &#40;Early Valve Replacement Guided by Biomarkers of LV Decompensation in Asymptomatic Patients with Severe AS&#44; Clinical Trials&#46;gov 03094143&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Unlike LGE&#44; which is insensitive for the detection of diffuse interstitial fibrosis&#44; T1 mapping techniques can provide overall assessments of the extracellular compartment&#46; While providing a close surrogate assessment of myocardial fibrosis&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> these markers are also affected by other extracellular factors including edema and capillary volume&#46; The most studied methods are native T1&#44; which does not require gadolinium contrast&#44; and extracellular volume fraction &#40;ECV&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> T1 mapping has provided important insight into the myocardium in AS&#44; most notably the potential for diffuse fibrosis to reverse post-AVR&#44; with an increasing body of evidence demonstrating its prognostic power in AS with other conditions &#40;cardiomyopathies&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">LV diastolic function is one of the earliest consequences of LVH and MF in AS&#46; LV diastolic dysfunction is associated with increased mortality&#44; worsens with progressive myocardial remodeling before AVR&#44; and gradually improves with reverse remodeling after AVR&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The improvement in diastolic dysfunction in AS takes longer than the reversal of LV systolic dysfunction &#40;the former is mainly related to longstanding LV structural changes while the latter also reflects afterload mismatch&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Although LVEF provides important information and guides therapy&#44; it is load-dependent and not an index of myocardial contractility&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Global longitudinal strain assessment of LV deformation detects earlier changes in myocardial function and enables a better understanding of progression to heart failure in AS&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> Speckle-tracking echocardiography allows for a multidirectional assessment of myocardial deformation&#46; In AS&#44; LV longitudinal strain is impaired&#44; especially in the basal segments&#44; and is a predictor of clinical events in asymptomatic AS &#40;the primary mechanism involved in the alteration of LV longitudinal strain in AS is LV fibrosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Moreover&#44; GLS also depends on the pattern of LV remodeling&#44; with lower values in patients with significant concentric LVH&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Recent studies have shown that GLS predicts postoperative LV dysfunction and outcomes better than ejection fraction&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Although this technique has high levels of acceptance and is widely available&#44; it exhibits several inherent limitations such as poor inter-reader reproducibility and need for an appropriate &#8220;acoustic window&#8221;&#46; Cardiac magnetic resonance feature tracking gives us the possibility of deriving deformation parameters from standard cine sequences and thus combine the advantages of both imaging modalities&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> However&#44; comparability between different vendors&#44; imaging modalities and post-processing software needs to be further assessed and proven&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Assessment of left ventricular reverse remodeling - EPICHEART Study</span><p id="par0090" class="elsevierStylePara elsevierViewall">Ideally&#44; surgery should be performed before irreversible changes occur in the myocardium&#46; Indeed&#44; rather than an isolated valve disease&#44; AS is a more global disease&#44; potentially affecting the entire myocardium&#46; Ejection fraction is the only LV parameter currently recommended to guide intervention in asymptomatic patients with AS&#44; with a cut-off value of 50&#37; for referral for AVR&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Future trials to establish clear thresholds and incorporating GLS into decision-making for asymptomatic patients with AS will be needed to establish its role as a marker of subclinical LV decompensation&#46; The traditional criteria for AVR are now being questioned based on our current understanding of pre-clinical myocardial disease in asymptomatic AS&#46; Echocardiographic and CMR assessment of myocardial deformation and myocardial fibrosis offer clear prognostic information above and beyond valve hemodynamic and LVEF alone&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Azevedo et al&#46; assessed the relationship between global and regional left ventricular strain&#44; strain rate&#44; displacement and velocity using CMR-FT and LVEF before and after AVR in a prospective cohort of AS patients&#46; One objective of this study was to assess reverse remodeling using CMR with standard functional and innovative deformation parameters in patients after six months of AVR &#40;EPICHEART Study&#41; and assess the prognostic impact&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In this study&#44; they found that there is a significant reduction in GLS and GCS CMR parameters after AVR&#44; with unchanged LVEF compared to baseline&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> The authors reported similar findings in several recent echocardiographic studies as well as some studies recently published with CMR-FT within three months of a successful transcatheter valve replacement &#40;TAVR&#41; in comparison to a healthy control group&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">As it was demonstrated that positive response after AVR &#40;surgical valve replacement or TAVR&#41; could be predicted by analyzing longitudinal strain and velocity&#44; it has been suggested that the assessment of cardiac mechanics could be useful for the right timing of AVR&#46; Nevertheless&#44; the prognostic implication of persistent subtle functional abnormalities after AVR remains poorly investigated and thus unclear&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> A correlation between deformation parameters and outcomes has not as yet been reported&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Randomized trials are needed to determine whether the use of fibrosis imaging biomarkers &#40;LGE&#41;&#44; T1 mapping and GLS can improve outcomes of asymptomatic patients with AS&#46; The EVOLVED-AS study<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> is an ongoing trial that should answer these crucial questions&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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