Global and Regional Longitudinal Strains Predict Left Ventricular Dysfunction after Mitral Valve Repair: A Two Dimensional Speckle Tracking Study


1 Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran

2 Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran

3 Echocardiography Research Center, Quaem Cardiovascular Medical and Research Center, Mashhad University of Medical Sciences, Mashhad, Iran


Abstract Background: It has been well documented that reduced left ventricular ejection fraction (LVEF) has adverse effect on the outcome of patients with severe mitral regurgitation (MR) after mitral valve repair (MVr). However, the best method for early detection of LV dysfunction in asymptomatic or mildly symptomatic patients with MR still has not been established. Recently two dimensional speckle tracking echocardiography (2DSTE) has been used to identify subclinical alterations of myocardial deformation in many clinical settings. Objectives: Our aim was to assess the value of regional and global LV two dimensional strains to predict postoperative LV dysfunction after MVr. Methods: Twenty six patients with severe MR were evaluated. Patients were divided into two groups according to their postoperative LVEF difference, those with a post-op LVEF reduction of < 10% at 3 months (Group 1), and those with post-op LVEF reduction of  10% at 3 months (Group 2). All data were measured after 3 months follow-up and compared with pre-operative measures. Results: The occurrence of post-operative LV dysfunction was significantly related to left ventricular end-systolic dimension index (LVESDI), NYHA functional class and global longitudinal strain (GLS). A cut-off value of 19% for GLS could predict post-op LV dysfunction with a sensitivity of 89% and specificity of 77%. In addition a cut-off value of - 17.7% for long axis strain with a sensitivity of 78% and specificity of 77% and a cut off value of -20% for 2-chamber strain with a sensitivity of 77% and specificity 83% could predict LV dysfunction after MVr. Conclusions: Among all measured data LV global longitudinal strain seems to be the most sensitive predictor of postoperative LV dysfunction in patients with severe MR and normal LVEF after surgical repair.


  1. 1.Di Dedda U, Pelissero G, Agnelli B, De Vincentiis C, Castelvecchio S, Ranucci M. Accuracy, calibration and clinical performance of the new EuroSCORE II risk stratification system. Eur J Cardiothorac Surg. 2013;43(1):27–32. doi: 10.1093/ejcts/ezs196. [PubMed: 22822108].

    1. Mor-Avi V, Lang RM, Badano LP, Belohlavek M, Cardim NM, Derumeaux G, et al. Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography. Eur J Echocardiogr. 2011;12(3):167–205. doi: 10.1093/ejechocard/jer021. [PubMed: 21385887].
    2. Pu M, Gao Z, Zhang X, Liao D, Pu DK, Brennan T, et al. Impact of mitral regurgitation on left ventricular anatomic and molecular remodeling and systolic function: implication for outcome. Am J Physiol Heart Circ Physiol. 2009;296(6):1727–32. doi: 10.1152/ajpheart.00882.2008. [PubMed: 19329766].
    3. Grigioni F, Tribouilloy C, Avierinos JF, Barbieri A, Ferlito M, Trojette F, et al. Outcomes in mitral regurgitation due to flail leaflets a multicenter European study. JACC Cardiovasc Imaging. 2008;1(2):133–41. doi: 10.1016/j.jcmg.2007.12.005. [PubMed: 19356418].
    4. Michelena HI, Bichara VM, Margaryan E, Forde I, Topilsky Y, Suri R, et al. Progress in the treatment of severe mitral regurgitation. Rev Esp Cardiol. 2010;63(7):820–31. [PubMed: 20609316].
    5. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med. 2005;352(9):875–83. doi: 10.1056/NEJMoa041451. [PubMed: 15745978].
    6. Rosenhek R, Rader F, Klaar U, Gabriel H, Krejc M, Kalbeck D, et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation. 2006;113(18):2238–44. doi: 10.1161/CIRCULATIONAHA.105.599175. [PubMed: 16651470].
    7. Blessberger H, Binder T. Two dimensional speckle tracking echocardiography: clinical applications. Heart. 2010;96(24):2032–40. doi: 10.1136/hrt.2010.199885. [PubMed: 21088126].
    8. Lee R, Marwick TH. Assessment of subclinical left ventricular dysfunction in asymptomatic mitral regurgitation. Eur J Echocardiogr. 2007;8(3):175–84. doi: 10.1016/j.euje.2006.11.002. [PubMed: 17240198].
    9. Tribouilloy C, Rusinaru D, Szymanski C, Mezghani S, Fournier A, Levy F, et al. Predicting left ventricular dysfunction after valve repair for mitral regurgitation due to leaflet prolapse: additive value of left ventricular end-systolic dimension to ejection fraction. Eur J Echocardiogr. 2011;12(9):702–10. doi: 10.1093/ejechocard/jer128. [PubMed: 21821606].
    10. Ahmed MI, Gladden JD, Litovsky SH, Lloyd SG, Gupta H, Inusah S, et al. Increased oxidative stress and cardiomyocyte myofibrillar degeneration in patients with chronic isolated mitral regurgitation and ejection fraction >60%. J Am Coll Cardiol. 2010;55(7):671–9. doi: 10.1016/j.jacc.2009.08.074. [PubMed: 20170794].
    11. Agricola E, Galderisi M, Oppizzi M, Schinkel AF, Maisano F, De Bonis M, et al. Pulsed tissue Doppler imaging detects early myocardial dysfunction in asymptomatic patients with severe mitral regurgitation. Heart. 2004;90(4):406–10. [PubMed: 15020516].
    12. de Isla LP, de Agustin A, Rodrigo JL, Almeria C, del Carmen Manzano M, Rodriguez E, et al. Chronic mitral regurgitation: a pilot study to assess preoperative left ventricular contractile function using speckletracking echocardiography. J Am Soc Echocardiogr. 2009;22(7):831–8. doi: 10.1016/j.echo.2009.04.016. [PubMed: 19505795].
    13. Kim MS, Kim YJ, Kim HK, Han JY, Chun HG, Kim HC, et al. Evaluation of left ventricular short- and long-axis function in severe mitral regurgitation using 2-dimensional strain echocardiography. Am Heart J. 2009;157(2):345–51. doi: 10.1016/j.ahj.2008.10.004. [PubMed: 19185644].
    14. Matsumura T, Ohtaki E, Tanaka K, Misu K, Tobaru T, Asano R, et al. Echocardiographic prediction of left ventricular dysfunction after mitral valve repair for mitral regurgitation as an indicator to decide the optimal timing of repair. J Am Coll Cardiol. 2003;42(3):458–63. [PubMed: 12906972].
    15. Enriquez-Sarano M, Tajik AJ, Schaff HV, Orszulak TA, McGoon MD, Bailey KR, et al. Echocardiographic prediction of left ventricular function after correction of mitral regurgitation: results and clinical implications. J Am Coll Cardiol. 1994;24(6):1536–43. [PubMed: 7930287].
    16. Witkowski TG, Thomas JD, Debonnaire PJ, Delgado V, Hoke U, Ewe SH, et al. Global longitudinal strain predicts left ventricular dysfunction after mitral valve repair. Eur Heart J Cardiovasc Imaging. 2013;14(1):69– 76. doi: 10.1093/ehjci/jes155. [PubMed: 22848021].
    17. Zile MR, Gaasch WH, Carroll JD, Levine HJ. Chronic mitral regurgitation: predictive value of preoperative echocardiographic indexes of left ventricular function and wall stress. J Am Coll Cardiol. 1984;3(2 Pt 1):235–42. [PubMed: 6693615].
    18. Borow KM, Green LH, Mann T, Sloss LJ, Braunwald E, Collins JJ, et al. End-systolic volume as a predictor of postoperative left ventricular performance in volume overload from valvular regurgitation. Am J Med. 1980;68(5):655–63. [PubMed: 7377221].
    19. Lee R, Haluska B, Leung DY, Case C, Mundy J, Marwick TH. Functional and prognostic implications of left ventricular contractile reserve in patients with asymptomatic severe mitral regurgitation. Heart. 2005;91(11):1407–12. doi: 10.1136/hrt.2004.047613. [PubMed: 16230438].
    20. Leung DY, Griffin BP, Stewart WJ, Cosgrove DM 3rd, Thomas JD, Marwick TH. Left ventricular function after valve repair for chronic mitral regurgitation: predictive value of preoperative assessment of contractile reserve by exercise echocardiography. J Am Coll Cardiol. 1996;28(5):1198–205. doi: 10.1016/S0735-1097(96)00281-1. [PubMed: 8890816]. Razavi Int J Med. 2017; 5(1):e41456. 7 Esmaeilzadeh M et al.
    21. Haluska BA, Short L, Marwick TH. Relationship of ventricular longitudinal function to contractile reserve in patients with mitral regurgitation. Am Heart J. 2003;146(1):183–8. doi: 10.1016/S0002- 8703(03)00173-X. [PubMed: 12851629].
    22. Gulati VK, Katz WE, Follansbee WP, Gorcsan J 3rd. Mitral annular descent velocity by tissue Doppler echocardiography as an index of global left ventricular function. Am J Cardiol. 1996;77(11):979–84. [PubMed: 8644649].
    23. Kjaergaard J, Korinek J, Belohlavek M, Oh JK, Sogaard P, Hassager C. Accuracy, reproducibility, and comparability of Doppler tissue imaging by two high-end ultrasound systems. J Am Soc Echocardiogr. 2006;19(3):322–8. doi: 10.1016/j.echo.2005.10.007. [PubMed: 16500496].
    24. Ingul CB, Torp H, Aase SA, Berg S, Stoylen A, Slordahl SA. Automated analysis of strain rate and strain: feasibility and clinical implications. J Am Soc Echocardiogr. 2005;18(5):411–8. doi: 10.1016/j.echo.2005.01.032. [PubMed: 15891750].
    25. Voigt JU, Pedrizzetti G, Lysyansky P, Marwick TH, Houle H, Baumann R, et al. Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. J Am Soc Echocardiogr. 2015;28(2):183–93. doi: 10.1016/j.echo.2014.11.003. [PubMed: 25623220].
    26. Seo Y, Ishizu T, Aonuma K. Current status of 3-dimensional speckle tracking echocardiography: a review from our experiences. J Cardiovasc Ultrasound. 2014;22(2):49–57. doi: 10.4250/jcu.2014.22.2.49. [PubMed: 25031794].