Prognosticating With Left Ventricular Global Longitudinal Strain: A New Opportunity for Cardiac Anesthesiologists.

Left ventricular ejection fraction (LVEF) lacks sensitivity for identifying subclinical LV impairment from subendocardial longitudinal fiber disease, which may not affect LVEF measurements.1Greenbaum R Ho SY Gibson D et al.Left ventricular fibre architecture in man.Heart. 1981; 45: 248-263Crossref Scopus (909) Google Scholar The LV strain is an echocardiographic measure of myocardial function capable of quantifying longitudinal, radial, and circumferential contractions.2Kalam K Otahal P Marwick TH. Prognostic implications of global LV dysfunction: A systematic review and meta-analysis of global longitudinal strain and ejection fraction.Heart. 2014; 100: 1673-1680Crossref PubMed Scopus (704) Google Scholar The LV longitudinal strain is extensively used in the outpatient setting to predict outcomes in patients with valvular heart disease,3Namazi F van der Bijl P Hirasawa K et al.Prognostic value of left ventricular global longitudinal strain in patients with secondary mitral regurgitation.J Am Coll Cardiol. 2020; 75: 750-758Crossref PubMed Scopus (42) Google Scholar cardiomyopathies,4Tower-Rader A Mohananey D To A et al.Prognostic value of global longitudinal strain in hypertrophic cardiomyopathy: A systematic review of existing literature.JACC Cardiovasc Imaging. 2019; 12: 1930-1942Crossref PubMed Scopus (79) Google Scholar or undergoing anthracycline chemotherapy5Poterucha JT Kutty S Lindquist RK et al.Changes in left ventricular longitudinal strain with anthracycline chemotherapy in adolescents precede subsequent decreased left ventricular ejection fraction.J Am Soc Echocardiogr. 2012; 25: 733-740Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar with a normal LVEF. Are cardiac anesthesiologists missing out on this vital parameter? We read with interest the retrospective study of Kang et al.6Kang H-U Nam J-S Kim J-H et al.Incremental prognostic value of left ventricular longitudinal strain over ejection fraction in coronary artery bypass grafting.J Cardiothorac Vasc Anesth. 2022; 36: 4305-4312Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar who demonstrated the incremental prognostic value of LV longitudinal strain in patients with preserved LVEF as a predictor of all-cause mortality after isolated coronary artery bypass graft surgery. The LV function was categorized as ‘preserved LVEF and preserved longitudinal strain,' ‘preserved LVEF but impaired longitudinal strain,' and ‘reduced LVEF ' (with impaired longitudinal strain by default).6Kang H-U Nam J-S Kim J-H et al.Incremental prognostic value of left ventricular longitudinal strain over ejection fraction in coronary artery bypass grafting.J Cardiothorac Vasc Anesth. 2022; 36: 4305-4312Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar As expected, mortality was highest in the cohort with impaired LV function. In the 2 cohorts with normal LVEF, longitudinal strain demonstrated a linear relationship with postoperative mortality (hazard ratio of 1.13 per % increase in LV strain > −15.5%, 95% CI 1.09-1.18, p < 0.001).6Kang H-U Nam J-S Kim J-H et al.Incremental prognostic value of left ventricular longitudinal strain over ejection fraction in coronary artery bypass grafting.J Cardiothorac Vasc Anesth. 2022; 36: 4305-4312Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Postoperative survival was greater in patients with normal LVEF with preserved rather than impaired longitudinal strain (90.0% v 84.6%, p = 0.002).6Kang H-U Nam J-S Kim J-H et al.Incremental prognostic value of left ventricular longitudinal strain over ejection fraction in coronary artery bypass grafting.J Cardiothorac Vasc Anesth. 2022; 36: 4305-4312Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The results suggested that LV longitudinal strain is valuable in stratifying risk in cardiac surgery patients, especially those with normal LVEF. We commend the authors of this pivotal study for their insightful work. Patients identified preoperatively to have decreased LV strain may benefit from afterload reduction and catecholamine suppression.7Pagel PS Tawil JN Boettcher BT et al.Heart failure with preserved ejection fraction: A comprehensive review and update of diagnosis, pathophysiology, treatment, and perioperative implications.J Cardiothorac Vasc Anesth. 2021; 35: 1839-1859Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Whether these findings may also be extended intraoperatively to affect anesthetic management in patients with American College of Cardiology-American Heart Association stage A heart failure (ie, subtle LV systolic dysfunction and preserved EF) is unresolved.8Members C Hunt SA Baker DW et al.ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: Executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure).Circulation. 2001; 104: 2996-3007Crossref PubMed Google Scholar The LV strain may be capable of detecting subtle impairments in LV systolic function before any reduction in LVEF becomes apparent.2Kalam K Otahal P Marwick TH. Prognostic implications of global LV dysfunction: A systematic review and meta-analysis of global longitudinal strain and ejection fraction.Heart. 2014; 100: 1673-1680Crossref PubMed Scopus (704) Google Scholar The benefit of obtaining LV strain may influence decision-making after bypass in patients with “normal LV systolic function" defined by LVEF alone. Specifically, the greater sensitivity of LV strain may allow anesthesiologists to more proactively initiate LV support, particularly in patients with subclinical subendocardial fiber failure. However, this hypothesis remains to be tested.9Benson MJ Silverton N Morrissey C et al.Strain imaging: An everyday tool for the perioperative echocardiographer.J Cardiothorac Vasc Anesth. 2020; 34: 2707-2717Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The current study identified patients with atrial fibrillation, regional wall motion abnormalities, and moderate-severe mitral regurgitation as those with impaired LV strain despite normal LVEF.6Kang H-U Nam J-S Kim J-H et al.Incremental prognostic value of left ventricular longitudinal strain over ejection fraction in coronary artery bypass grafting.J Cardiothorac Vasc Anesth. 2022; 36: 4305-4312Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar These patients, and those with heart failure with preserved LVEF, may benefit from intraoperative LV strain analysis because LVEF alone insufficiently prognosticates the acute declines in LV function during or after surgery, as evidenced by the poorer all-cause postoperative mortality compared to nonheart-failure patients.7Pagel PS Tawil JN Boettcher BT et al.Heart failure with preserved ejection fraction: A comprehensive review and update of diagnosis, pathophysiology, treatment, and perioperative implications.J Cardiothorac Vasc Anesth. 2021; 35: 1839-1859Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar None. Incremental Prognostic Value of Left Ventricular Longitudinal Strain Over Ejection Fraction in Coronary Artery Bypass GraftingJournal of Cardiothoracic and Vascular AnesthesiaVol. 36Issue 12PreviewTo evaluate the incremental prognostic value of longitudinal strain over left ventricular ejection fraction (LVEF) after coronary artery bypass grafting (CABG). Full-Text PDF