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

  • 1Department of Echocardiography, Ignacio Chávez National Cardiology Institute, Mexico City, Mexico. vazzny74@yahoo.com
  • 2Department of Molecular Biology, Ignacio Chávez National Cardiology Institute, Mexico City, Mexico.
  • 3Department of Surgery, Ignacio Chávez National Cardiology Institute, Mexico City, Mexico.
  • 4Department of Pathology, Ignacio Chávez National Cardiology Institute, Mexico City, Mexico.
  • 5Intermediate Care Unit, Médica Sur Clinical Foundation, Mexico City, Mexico.


Severe aortic stenosis (AS), leads to pathological left ventricular remodeling that may worsen with concomitant overweight and obesity (OW/O).
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.
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.
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.


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

MeSH Terms

Aortic Valve Stenosis*
Body Mass Index
Endomyocardial Fibrosis
Multivariate Analysis
Prospective Studies
Sensitivity and Specificity
Stroke Volume
Ventricular Remodeling


  • 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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Jin Kyung Oh, Jae-Hyeong Park, Jin Kyung Hwang, Chang Hoon Lee, Jong Seon Park, Joong-Il Park, Hoon-Ki Park, Jung Sun Cho, Bong-suk Seo, Seok-Woo Seong, Byung Joo Sun, Jae-Hwan Lee, In-Whan Seong
Korean Circ J. 2019;49(2):160-169.    doi: 10.4070/kcj.2018.0208.


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