J Cardiovasc Ultrasound.  2016 Dec;24(4):303-311. 10.4250/jcu.2016.24.4.303.

Echocardiographic and Histologic Correlations in Patients with Severe Aortic Stenosis: Influence of Overweight and Obesity

• Ávila-Vanzzini N
• Fritche-Salazar JF
• Vázquez-Castro NM
• Rivera-Lara P
• Pérez-Méndez O
• Martínez-Herrera H
• Gómez-Sánchez M
• Aranda-Frausto A
• Herrera-Bello H
• Luna-Luna
• Arias Godínez JA

• KMID: 2364648
• DOI: http://doi.org/10.4250/jcu.2016.24.4.303

Abstract

BACKGROUND
Severe aortic stenosis (AS), leads to pathological left ventricular remodeling that may worsen with concomitant overweight and obesity (OW/O).
METHODS
We aimed to prospectively analyze the impact of OW/O on ventricular remodeling in severe AS, by evaluating the percentage of intraendomyocardial fibrosis (PIEF) and the percentage of infiltrating intraendocardial lipid vacuoles (PIELV) and its relationship to global longitudinal strain (GLS) in patients with OW/O.
RESULTS
44 patients with severe AS were included, 13 non-obese (29%) and 31 OW/O (71%), all of them with left ventricular ejection fraction ≥ 55%. GLS was evaluated with 2D speckle tracking. During valve replacement, an endocardial biopsy was obtained, where PIEF and PIELV were analyzed. Patients with higher PIEF and PIELV had greater body mass index (p < 0.0001) and worse GLS (p < 0.0053). A GLS cut-off point < -14% had a sensitivity of 75%, and a specificity of 92.8% to detect important PIEF (AUC: 0.928, 95% confidence interval: 0.798-1.00). On multivariate analysis, OW/O and PIELV were independently associated to the PIEF, and OW/O and PIEF were independently associated to GLS. A high correlation between the amount of PIELV and PIEF were found.
CONCLUSION
Patients with severe AS and OW/O have greater PIEF and PIELV, suggesting more pathological remodeling. GLS is useful to detect subclinical myocardial injury and is potentially useful for endomyocardial fibrosis detection. The presence of higher PIELF may be a trigger factor for the development of intraendomyocardial fibrosis.

Keyword

Severe aortic stenosis; Overweight and obesity; Intraendomyocardial fibrosis; Global longitudinal strain

MeSH Terms

Aortic Valve Stenosis*
Biopsy
Body Mass Index
Echocardiography*
Endomyocardial Fibrosis
Fibrosis
Humans
Multivariate Analysis
Obesity*
Overweight*
Prospective Studies
Sensitivity and Specificity
Stroke Volume
Vacuoles
Ventricular Remodeling

Figure

• 

  Fig. 1 Left ventricular function and obesity. A: Scatter plot showing the body mass index (BMI) and global longitudinal strain (GLS) as continuous variables. B: Increased risk of systolic subclinical dysfunction (SSD) by unit of BMI, odds ratios are shown with its 95% confidence intervals (CIs).

• 

  Fig. 2 Microphotographs of myocardial biopsies. A: Focal adipose infiltration evidenced by the presence of adipocytes (arrow) and a small area of hemorrhage (arrowhead) resulting from the procedure (Masson × 10). B: Myocardial fascicles pointing in different directions and thin connective tissue septa separating them (blue); no adipocytes are observed (Masson × 4). C: Extensive area of fibrosis in blue contrasting with the red myocardium (Masson × 10). D: Muscle fascicles (red) pointing in different directions and limited by thin connective tissue septa. The myocardium shows evidence of fibrosis in a small subendocardial area (arrow) (Masson × 10). E: Myocardial microphotograph after lipid staining. Abundant reddish vacuoles are observed in the myocyte cytoplasm (Oil Red × 40). F: No red vacuoles are observed within the fibers (Oil Red × 40). OW/O: overweight or obesity.

• 

  Fig. 3 Difference in body mass index by % of myocardial fibrosis infiltration (A) and myocardial fatty infiltration (B). Difference in global longitudinal strain according to the % of myocardial fibrosis infiltration (C) and % myocardial fatty infiltration (D), expressed as categorical variables. BMI: body mass index.

• 

  Fig. 4 Receiver operating characteristic (ROC) curve for the detection of > 50% intramyocardial fibrosis by global longitudinal strain.

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