que se leu este artigo
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class="elsevierStyleSimplePara elsevierViewall">End-diastolic endocardial (red) and epicardial (green) contours of the left ventricle in a four-chamber image (A) and on a short-axis view (B) using tissue-tracking, and global left ventricular longitudinal (C), circumferential (D), and radial (E) strain curves.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Diana Azevedo, Jennifer Mancio, Guilherme Pessoa-Amorim, David Monteiro, Nuno Almeida, Ricardo Ladeiras-Lopes, Rita Faria, Nuno Ferreira, Luís Vouga, Vasco Gama Ribeiro, Adelino Leite-Moreira, Nuno Bettencourt" "autores" => array:12 [ 0 => array:2 [ "nombre" => "Diana" "apellidos" => "Azevedo" ] 1 => array:2 [ "nombre" => "Jennifer" "apellidos" => "Mancio" ] 2 => array:2 [ "nombre" => "Guilherme" "apellidos" => "Pessoa-Amorim" ] 3 => array:2 [ "nombre" => "David" "apellidos" => "Monteiro" ] 4 => array:2 [ "nombre" => "Nuno" "apellidos" => "Almeida" ] 5 => array:2 [ "nombre" => "Ricardo" "apellidos" => 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Ready for prime time?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "165" "paginaFinal" => "167" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Luís M. Moura" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Luís M." "apellidos" => "Moura" "email" => array:1 [ 0 => "luismoura@med.up.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Centro de Investigação em Tecnologias e Serviços de Saúde (CINTESIS), Faculty of Medicine, Department of Medicine, University of Porto, Porto, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Utilidade da imagiologia cardiovascular avançada na substituição valvular aórtica. Pronta para o horário nobre" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Over the last decade, research into left ventricular (LV) structure and function in patients with aortic stenosis (AS) has increased, due to improvements in imaging modalities and potential therapies. This has prompted a focus on subclinical changes in LV function, as well as the degree of reversibility of LV structural changes in advanced stages of AS. These factors may influence the optimal timing of valve intervention.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of the Portuguese Cardiology Journal, Azevedo et al. sought to compare cardiac magnetic resonance (CMR) assessed global radial strain (GRS), global circumferential strain (GCS), and global longitudinal strain (GLS) 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.<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 (LVH) is poorly linked to AS severity,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> suggesting that other factors are also involved in its development. Age, gender, angiotensin-converting enzyme I/D polymorphism, co-existing coronary artery disease and hypertension are additional factors influencing LV response to AS.<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.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> The mechanisms governing the development and progression of myocardial fibrosis (MF) are not fully understood. Myocardial fibrosis has traditionally been categorized as diffuse interstitial fibrosis (appears to be reversible with afterload relief) or replacement fibrosis (myocyte necrosis).</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. Linear LV dimensions must be measured to calculate the LV mass and LV mass index for LV remodeling classification,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> however it has several limitations relative to CMR (poor acoustic windows, misaligned LVs, difficulties in delineating the posterior wall, inaccurate estimation of the LV mass in the presence of asymmetrical hypertrophy, etc.).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Certain remodeling patterns are associated with a worse outcome, and there may be sexual dimorphism in the myocardial response to AS.<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, 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: increasing myocyte size eventually leads to myocyte apoptosis and subsequent replacement fibrosis, possibly explaining the transition from hypertrophy to heart failure.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> In AS, MF, defined as a significant increase in the collagen volume fraction of myocardial tissue, is a complex process involving at least three main alterations: endocardial thickening, subendocardial microscars, and diffuse interstitial fibrosis.<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, it is invasive and has some limitations (mainly sampling errors and the inability to assess MF globally). Cardiac magnetic resonance is the only non-invasive alternative that enables direct global assessment of MF,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> using two approaches: late gadolinium enhancement (LGE) and myocardial T1 mapping. LGE enables the quantification of focal interstitial expansion, with direct visualization of focal replacement fibrosis, whereas myocardial T1 mapping assesses the diffuse interstitial expansion of fibrosis.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Replacement fibrosis is detected with CMR using LGE<span class="elsevierStyleBold">.</span> Beta gadolinium-based contrast agents partition into extracellular space and wash out of areas of focal fibrosis slower than healthy tissue. Multiple studies have consistently shown strong independent associations between ischemic and non-ischemic LGE and both cardiovascular and all-cause mortality. Furthermore, 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.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> Importantly, this fibrosis does not regress after aortic valve replacement (AVR);<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8,10</span></a> the burden of scarring that develops while awaiting surgery persists in patients for life. This is important because the greater the MF, the worse the long-term prognosis is.<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. Clinical implementation of LGE to optimize the timing of aortic valve intervention is being tested in the randomized EVOLVED-AS trial (Early Valve Replacement Guided by Biomarkers of LV Decompensation in Asymptomatic Patients with Severe AS, Clinical Trials.gov 03094143).<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Unlike LGE, which is insensitive for the detection of diffuse interstitial fibrosis, T1 mapping techniques can provide overall assessments of the extracellular compartment. While providing a close surrogate assessment of myocardial fibrosis,<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. The most studied methods are native T1, which does not require gadolinium contrast, and extracellular volume fraction (ECV%).<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> T1 mapping has provided important insight into the myocardium in AS, most notably the potential for diffuse fibrosis to reverse post-AVR, with an increasing body of evidence demonstrating its prognostic power in AS with other conditions (cardiomyopathies).<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. LV diastolic dysfunction is associated with increased mortality, worsens with progressive myocardial remodeling before AVR, and gradually improves with reverse remodeling after AVR.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The improvement in diastolic dysfunction in AS takes longer than the reversal of LV systolic dysfunction (the former is mainly related to longstanding LV structural changes while the latter also reflects afterload mismatch).<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, it is load-dependent and not an index of myocardial contractility.</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.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> Speckle-tracking echocardiography allows for a multidirectional assessment of myocardial deformation. In AS, LV longitudinal strain is impaired, especially in the basal segments, and is a predictor of clinical events in asymptomatic AS (the primary mechanism involved in the alteration of LV longitudinal strain in AS is LV fibrosis).<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Moreover, GLS also depends on the pattern of LV remodeling, with lower values in patients with significant concentric LVH.<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.<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, it exhibits several inherent limitations such as poor inter-reader reproducibility and need for an appropriate “acoustic window”. 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.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> However, comparability between different vendors, imaging modalities and post-processing software needs to be further assessed and proven.</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, surgery should be performed before irreversible changes occur in the myocardium. Indeed, rather than an isolated valve disease, AS is a more global disease, potentially affecting the entire myocardium. Ejection fraction is the only LV parameter currently recommended to guide intervention in asymptomatic patients with AS, with a cut-off value of 50% for referral for AVR.<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. The traditional criteria for AVR are now being questioned based on our current understanding of pre-clinical myocardial disease in asymptomatic AS. Echocardiographic and CMR assessment of myocardial deformation and myocardial fibrosis offer clear prognostic information above and beyond valve hemodynamic and LVEF alone.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Azevedo et al. assessed the relationship between global and regional left ventricular strain, strain rate, displacement and velocity using CMR-FT and LVEF before and after AVR in a prospective cohort of AS patients. 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 (EPICHEART Study) and assess the prognostic impact.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In this study, they found that there is a significant reduction in GLS and GCS CMR parameters after AVR, with unchanged LVEF compared to baseline.<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 (TAVR) in comparison to a healthy control group.<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 (surgical valve replacement or TAVR) could be predicted by analyzing longitudinal strain and velocity, it has been suggested that the assessment of cardiac mechanics could be useful for the right timing of AVR. Nevertheless, the prognostic implication of persistent subtle functional abnormalities after AVR remains poorly investigated and thus unclear.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> A correlation between deformation parameters and outcomes has not as yet been reported.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Randomized trials are needed to determine whether the use of fibrosis imaging biomarkers (LGE), T1 mapping and GLS can improve outcomes of asymptomatic patients with AS. 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.</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.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Assessing the consequence of aortic stenosis for the left ventricle" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "LV remodeling characterization" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Left ventricular fibrosis, left ventricular diastolic and systolic function" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Assessment of left ventricular reverse remodeling - EPICHEART Study" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left ventricular reverse remodeling and function by strain analysis in aortic stenosis: a CMR analysis of EPICHEART study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.M.J Azevedo" 1 => "J. 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