Assessment of Left Ventricular Global Longitudinal Strain Improvement Following Transcatheter Aortic Valve Replacement

Abstract

Background:

Transcatheter aortic valve replacement (TAVR) is a well-established therapeutic option for all risk patients with symptomatic severe aortic stenosis (AS). While TAVR primarily addresses AS, its benefits extend beyond the valve itself. Recent studies suggest possible restoration of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) following TAVR. This study aims to assess changes in LV GLS in patients undergoing TAVR, which may serve as a subclinical indicator of improved LV mechanics.

Materials and Methods:

This retrospective study included patients with severe AS who underwent TAVR at the American University of Beirut Medical Center from January 2017 to January 2023. Baseline and 1-year echocardiography parameters were compared, and GLS was calculated to assess the impact of TAVR on LV function.

Results:

A total of 80 patients (mean age: 81.3 ± 7.8 years; 38.8% of women; 88.8% hypertensive) who underwent TAVR for severe AS were included in the final analysis. One-year post-TAVR, echocardiographic studies showed a significant reduction in interventricular septum diameter (13.3 ± 2.3 mm vs. 12 ± 1.8 mm, P < 0.001) and LV mass index (LVMI) (113.6 ± 26.6 g/m² vs. 96 ± 30.3 g/m², P < 0.001). LVEF showed a modest improvement (59.2 ± 12.3% vs. 62.1 ± 7.6%, P < 0.01). LV GLS significantly improved from −16.8 ± 4.6% to −19.2 ± 3.3% (P < 0.001). Baseline LVMI, LVEF, and GLS correlate with the GLS change (ΔGLS) post-TAVR.

Conclusion:

GLS significantly improves 1 year after TAVR, indicating an overall improvement in LV performance. The degree of improvement in GLS correlates with baseline LVMI and systolic function.

INTRODUCTION

Aortic stenosis (AS) is one of the most prevalent valvular heart diseases, particularly in the elderly population.[1] Conventionally, AS management relied on open surgical aortic valve replacement (SAVR). Studies have demonstrated improvements in left ventricular (LV) systolic function following SAVR, as measured by LV ejection fraction (LVEF), tissue Doppler imaging, and speckle-tracking strain imaging.[2,3,4] However, this surgical approach carries a significant mortality risk in high-risk patients, limiting its applicability in this subgroup.

The introduction of transcatheter aortic valve replacement (TAVR) has offered a less invasive alternative, especially for high-risk AS patients. Studies have shown the efficacy and safety of TAVR in both the short- and long-term postprocedural periods, with notable reductions in major vascular complications, life-threatening bleeding, and major bleeding.[5,6,7] In addition, TAVR has been associated with rapid LV geometry recovery and reduced estimated filling pressure compared to SAVR.[8]

Strain by speckle-tracking echocardiography is a technique that evaluates both global and regional LV function. This technique calculates the global longitudinal strain (GLS), which has been shown to be more reliable for serial assessment of LV function[9] and even superior to LVEF for diagnosing and excluding acute coronary disease.[10] In addition, GLS is emerging as a valuable echocardiographic tool for identifying subclinical cardiac diseases. It not only enhances prognostication, diagnosis, and prediction of LVEF recovery but also may serve as a more accurate measure of LV dysfunction.[11] Given its advantages in assessing LV function, particularly in cases of mild systolic dysfunction, the clinical application of GLS is increasing.[12]

Following AVR, there is an immediate reduction in LV afterload and wall stress, which may lead to reverse LV remodeling over time.[13] This process is characterized by decreased LV mass, myocardial fibrosis, and LV end-diastolic pressure. In addition, there is an enhancement in the subendocardial myocardial perfusion during diastole, leading to an improvement in LV longitudinal function.[4,14]

While TAVR primarily addresses AS, its benefits may extend beyond the aortic valve. Recent research has suggested potential improvements in LVEF and GLS following TAVR.[15] Given the well-studied improvements in LV systolic function after SAVR, it is reasonable to investigate whether similar benefits may be observed in TAVR patients. However, the current literature is limited in its exploration of the long-term impact of TAVR on GLS, with many studies focusing primarily on immediate postoperative outcomes. This lack of comprehensive data on the sustained effects of TAVR on myocardial function, particularly subclinical indicators like GLS, highlights a significant gap in the existing research.

In their study, Løgstrup et al. examined 81 patients who underwent transfemoral or transapical aortic valve replacement. Evaluation of the LVEF and GLS in both groups indicated an enhanced systolic function. However, the improvement in GLS after 1 year did not correlate with an improvement in systolic function. Notably, when the patients were categorized based on their initial LVEF levels, those with lower baseline values (<50%) exhibited a greater enhancement in GLS and EF compared to those with preserved EF (>50%).[16]

Given the evolving landscape of cardiac interventions, understanding the full scope of TAVR’s impact is essential. While initial outcomes focus on survival and symptom relief, subtler aspects like GLS, an indicator of myocardial function, require more attention. This study aims to fill existing knowledge gaps by systematically evaluating TAVR’s effects on GLS, thereby refining patient management strategies and outcomes, especially in asymptomatic severe AS patients with low GLS.

MATERIALS AND METHODS

Study population

This retrospective observational study aimed to assess the 1-year impact of TAVR on GLS in patients with severe AS. The study population comprised adult patients with severe AS (as defined by the 2020 ACC/AHA guideline for the management of patients with valvular heart disease),[17] referred for TAVR at the American University of Beirut Medical Center (AUBMC) from January 2017 to January 2023. The study was approved by the Institutional Review Board (IRB) of AUBMC (IRB BIO-2023-0142). Patient demographics and medical history were retrieved from the TAVR registry (IRB ID: BIO-2019-0436).

Inclusion and exclusion criteria

We included patients who underwent TAVR with transthoracic echocardiography (TTE) performed within 1 month before TAVR and a follow-up TTE 8–16 months after the procedure. Patients were excluded if they had severe ischemic cardiomyopathy (LVEF <20%), developed left bundle branch block (LBBB) post-TAVR, had a cardiac device (pacemaker or cardiac resynchronization therapy-defibrillator (CRT-D), underwent TAVR for severe aortic regurgitation (AR), or had valve-in-valve TAVR.

Echocardiography

All patients underwent standard echocardiography using Philips EPIQ or GE Vivid E9 and E95 machines. LV dimensions were measured in the parasternal long-axis view at end-diastole at the level of the mitral leaflet tips, perpendicular to the long axis of the ventricle. This included interventricular septum diameter, end-diastolic LV diameter, and posterior wall diameter. The two-dimensional (2D)-LV mass index (LVMI) was calculated using the following equation:

where LVIDd is the LV internal diameter end diastole, interventricular septum thickness (IVST) is the end-diastolic interventricular septal wall thickness, and PWT is end-diastolic LV posterior wall thickness.[18] LV mass was indexed to the body surface area (BSA) using the Mosteller formula:

LVEF was obtained using the modified Simpson method in apical four-chamber and two-chamber views. The mean transvalvular pressure gradient (MPG) was calculated using the Bernoulli formula. The aortic valve area (AVA) was measured using the continuity equation. Early diastolic velocity (E) was measured by pulsed-wave Doppler sampling just above the mitral leaflet tips in the apical four-chamber view. Early diastolic tissue velocity (e’) was measured by tissue Doppler sampling at the lateral mitral valve annulus in the apical four-chamber view. The E/e’ ratio was calculated to estimate LV filling pressure. The left atrial volume index (LAVI) was measured using the disc summation algorithm and indexed to BSA using the Mosteller formula. RV systolic function was assessed according to current guidelines using tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), and tissue Doppler-derived tricuspid lateral annular systolic velocity (S’). RV dysfunction was defined if any of these parameters fell below respective normal cutoff values (TAPSE <17 mm, FAC <35%, or S’ <9.5 cm/s). Systolic pulmonary artery pressure (sPAP) was estimated by adding the tricuspid regurgitation pressure gradient, calculated using the modified Bernoulli equation, to the estimated right atrial pressure based on inferior vena cava diameter and respiratory variation, according to current guidelines.

Speckle-tracking echocardiography

Strain analysis was performed using TOMTEC software (TOMTEC Imaging Systems GmbH, Munich, Germany) in duplicate and independently. In concordance with the American Society of Echocardiography guidelines, 2D apical four-chamber, three-chamber, and two-chamber views were obtained during two consecutive cardiac cycles and acquired during breath-hold to ensure high-quality images and avoid foreshortening. The endocardial border was manually traced at end-diastole and end-systole, and the software automatically tracked myocardial movement throughout the cardiac cycle using a 17-segment model. GLS was measured as the average relative length change of the LV myocardium throughout the cardiac cycle, expressed as a percentage.

Statistical analysis

Data were analyzed using Microsoft Excel (Microsoft, Redmond, WA), SPSS statistics (IBM, Armonk, NY), and R in RStudio (R Foundation for Statistical Computing, Vienna, Austria). Continuous variables were reported as means with standard deviations (SD), and categorical variables as frequencies with percentages. Differences between pre- and post-TAVR values were assessed for statistical significance using the paired t-test for normally distributed data, and the Wilcoxon signed-rank test for non-normally distributed data. Statistical significance was defined as P < 0.05.

An automated regression analysis in RStudio examined the relationship between baseline echocardiographic characteristics and GLS, as well as changes in GLS (ΔGLS). Each baseline characteristic was analyzed against GLS, and these characteristics were correlated with ΔGLS to identify significant predictors of GLS changes postprocedure.

Multivariable regression analysis was conducted to adjust for potential confounding effects in the association between baseline GLS and its change post-TAVI. Covariates were selected based on clinical relevance and prior literature and included demographic factors (age, gender, and body mass index), comorbidities (hypertension, diabetes, chronic kidney disease, coronary artery disease [CAD], etc.), and preoperative echocardiographic parameters (LVMI, LVEF, GLS, NYHA class, etc.).

Interobserver variability was assessed by two independent investigators by randomly selecting 10 patients. Intraclass correlation coefficients (ICCs) were calculated for total agreement, with good agreement defined as an ICC >0.8. Means and SDs between the measurements were also obtained.

RESULTS

A total of 417 consecutive patients underwent TAVR during the study period. Of these, 107 patients had pre- and post-TAVR TTEs done at our institution and adequate echocardiographic image quality for strain analysis. The primary reason for exclusion was the insufficient echocardiographic image quality for strain analysis and/or lack of follow-up TTE post-TAVR (N = 310) [Figure 1]. Due to the complexity of our healthcare system and the fact that AUBMC serves as a referral center for TAVR procedures, many follow-up TTEs were performed outside our institution, which significantly reduced the available sample. In addition, 10 patients were excluded due to the development of LBBB post-TAVR or the presence of a cardiac device (pacemaker or CRT-D), which affects speckle tracking and LV strain analysis. An additional 8 patients were excluded due to severe ischemic cardiomyopathy (LVEF <20%) with regional wall motion abnormality, and 9 patients were excluded who underwent TAVR for severe AR. The final analysis included 80 patients who had pre-TAVR TTE (within 0–1 month) and post-TAVR TTE (8–16 months) with good-quality images for strain analysis [Figure 1]. Seven patients with ischemic cardiomyopathy and EF >20% were included in the study. The mean follow-up echocardiography post-TAVR was performed at 12 ± 3.5 months.

Figure 1.

Patient selection flowchart. TAVR = Transcatheter aortic valve replacement, EF = Ejection fraction, TTE = Transthoracic echocardiography

The baseline characteristics and comorbidities of the study population are summarized in Table 1. The mean age of the cohort was 81.3 ± 7.8 years, with 31 patients (38.8%) being women. Most individuals (71.3%) were never smokers, and 88.8% had hypertension. Thirty-eight patients (47.5%) had a history of CAD) with no acute coronary syndrome occurring during the follow-up period. Twenty-six of the 38 patients with CAD had a history of coronary intervention more than 1 year before TAVR, 10 patients had nonobstructive CAD, and only 2 patients had coronary intervention during TAVR. Both these patients had improvement of only less than 1 unit in GLS. Only 28.8% of the patients had heart failure, and the mean NYHA class pre-TAVR was 3.

Table 1.

Baseline characteristics of patients

Characteristic	Percentage
Total number	n=80
Age (years), mean±SD	81.3±7.8
Female	38.8
BMI	28.4±5.2
Smoking
Nonsmoker	82.5
Smoker	17.5
Medical history
Hypertension	88.8
Dyslipidemia	72.5
CAD	47.5
Type 2 diabetes mellitus	46.3
Chronic lung disease	22.5
Stroke	8.8
Transient ischemic attack	3.8
Chronic kidney disease	31.3
Heart failure	28.8
HFrEF	10
HFmrEF	5
Ischemic cardiomyopathy	8.75
NYHA class, mean±SD	3.2±0.6
Aortic valve area (cm2), mean±SD	0.8±0.2
BSA (m2), mean±SD	1.82±0.22

BMI=Body mass index, CAD=Coronary artery disease, NYHA=New York Heart Association, HFrEF=Heart failure with reduced ejection fraction, HFmrEF=Heart failure with mid-range ejection fraction, BSA=Body surface area, SD=Standard deviation

The echocardiographic parameters obtained are presented in Table 2. The preprocedural LVMI was 113.6 ± 26.6 g/m², the MPG was 46.9 ± 16.3 mmHg, and the LVEF was 59.2 ± 12.3% with a GLS of − 16.8 ± 4.8%. Baseline lateral e’ was 6.6 ± 2 cm/s, the E/e’ ratio was 16.8 ± 7.2, and the LAVI was 51.2 ± 18.0 mL/m², indicating impaired LV relaxation and elevated filling pressure.

Table 2.

Pre- and posttranscatheter aortic valve replacement echocardiographic parameters

Parameter	Pre-TAVR, mean±SD	Post-TAVR, mean±SD	Mean difference	95% CI of difference	P
IVST (mm)	13.3±2.3	12.0±1.8	−1.3	0.8–1.8	<0.001
EDD (mm)	45.9±6.1	45.3±5.7	−0.5	−0.6–2.0	0.309
PWT (mm)	10.8±1.7	10.1±1.4	−0.7	0.3–1.1	<0.01
LV mass (g)	207.6±55.9	177.4±69.2	−30.2	15.7–47.3	<0.001
LVMI (g/m2)	113.6±26.6	96.0±30.3	−17.5	9.6–26.3	<0.001
Vmax (cm/s)	417.5±78.8	198.7±53.4	−218.8	198.8–238.7	<0.001
MPG (mmHg)	46.9±16.3	9.4±5.3	−37.5	33.7–41.4	<0.001
SPAP	47.2±17.9	43.0±15.4	−4.3	−8.9–−0.1	<0.05
RV dysfunction (%)*	11.3	13.8	NA	NA	0.724
E/e’	16.8±7.2	16.3±7.5	−15.7	−17.4–−13.9	<0.001
E’ lateral (cm/s)	6.6±2.0	7.3±2.0	0.7	−1.1–−0.2	<0.01
LAVI (mL/m2)	51.2±18.0	47.9±16.6	−3.3	0.3–7.0	<0.05
LVEF (%)	59.2±12.3	62.1±7.6	0.03	−0.05–−0.01	<0.01
GLS (%)	−16.8±4.6	−19.2±3.3	−2.4	1.7–3.1	<0.001

*Mildly decreased, moderately decreased, and severely decreased. EDD=End-diastolic diameter, GLS=Global longitudinal strain, IVST=Interventricular septal thickness, LAVI=Left atrial volume index, LVEF=Left ventricular ejection fraction, LVMI=Left ventricular mass index, MPG=Mean pressure gradient, PWT=Posterior wall thickness, RV=Right ventricle, SPAP=Systolic pulmonary arterial pressure, V_max=Maximum velocity, TAVR=Transcatheter aortic valve replacement, LV=Left ventricle, SD=Standard deviation, NA=Not available, CI=Confidence interval

Nine patients had RV dysfunction before TAVR, of which three improved to normal. After TAVR, five patients developed new RV dysfunction. Overall, the percentage of patients with RV dysfunction did not change after TAVR (11.3% pre- vs. 13.8% post-TAVR with P = 0.725).

Fifty-six percent of patients were found to have pulmonary hypertension, as defined by SPAP >40 mmHg, and the mean of SPAP pre-TAVR was 47 ± 17.9 mmHg significantly decreasing to 43 ± 15.4 mmHg after TAVR with P < 0.05.

TAVR success was achieved in all cases, evidenced by a significant reduction in peak aortic velocity from 417.5 ± 78.8 cm/s to 198.7 ± 53.4 cm/s and in MPG from 46.9 ± 16.3 mmHg to 9.4 ± 5.3 mmHg (P < 0.001 for both). The IVST decreased from 13.3 ± 2.3 mm to 12 ± 1.8 mm (P < 0.001), with an overall significant reduction in LVMI from 113.6 ± 26.6 g/m² to 96 ± 30.3 g/m² post-TAVR. There was minimal improvement in LV relaxation parameters post-TAVR, including lateral e’ from 6.6 ± 2 cm/s to 7.3 ± 2 cm/s and E/e’ from 16.8 ± 7.2 to 16.3 ± 7.5. The LAVI significantly improved from 51.2 ± 18.0 mL/m² to 47.9 ± 16.6 mL/m² post-TAVR. In addition, the LVEF showed a modest improvement from 59.2 ± 12.3% to 62.1 ± 7.6% (P < 0.01). However, the GLS significantly improved from − 16.8 ± 4.6% to − 19.2 ± 3.3% (P < 0.001), as illustrated in Figure 2.

Figure 2.

Box and Whisker plot comparing global longitudinal strain pre- and posttranscatheter aortic valve replacement. GLS = Global longitudinal strain, TAVR = Transcatheter aortic valve replacement

In our study, LV GLS imaging demonstrated a high interobserver agreement, with a Cronbach’s alpha (α) of 0.974 based on standardized items, confirming the reliability of this imaging technique in evaluating LV function.

Regression analysis revealed that LVMI, LVEF, and GLS pre-TAVR correlate significantly with the change of GLS post-TAVR (P < 0.001).

DISCUSSION

The severity and classification of AS have traditionally been assessed based on the patient’s symptoms and LVEF.[17] However, it is increasingly recognized that LV remodeling due to AS-induced pressure overload occurs before any measured decline in LVEF.[19,20,21] While traditional echocardiography effectively identifies global LV dysfunction, tissue Doppler imaging, particularly strain imaging, is superior for detecting subtle systolic myocardial dysfunction before the onset of global LV dysfunction.[13] In addition, GLS imaging allows for the assessment of the function of each segment of the LV.

The chronic increase in afterload in severe AS leads to progressive LV remodeling, an adaptive mechanism in response to elevated wall stress. Over time, however, this process can potentially result in myocardial fibrosis.[22] Consequently, there is a gradual decline in LV diastolic relaxation and overall performance.[23] LVEF can still be preserved at this stage, although progressive impairment of longitudinal strain can be detected. In our study, the mean LVEF in severe AS was 59.2 ± 12.3%, while GLS was at the lower limit of normal with a mean of −16.8 ± 4.6%.

Our study revealed a significant improvement in LV systolic function at the 1-year follow-up, evidenced by a considerable increase in GLS, as shown in Figure 2. The increase in LV GLS is consistent with findings from other studies.[24,25,26] Suzuki et al. evaluated the acute response to TAVR 1-week postprocedure, showing a mean improvement of 1 point in GLS.[25] Giannini et al. demonstrated that strain improved at the septal and lateral myocardial walls as early as 72 h after TAVR.[13]

The acute improvement in GLS is likely a consequence of pressure unloading following the relief of AS immediately post-TAVR.[13] Our study, with a follow-up period extending to one year, showed an improvement reaching 2.4 points in GLS, increasing from −16.8 ± 4.6% to − 19.2 ± 3.3%. This ongoing late recovery can be attributed to the significant reduction in LV mass and the concomitant decrease in collagen and extracellular matrix protein content, alongside the regression of diffuse fibrosis and myocardial cellular hypertrophy.[13,22] Our results demonstrated that LVMI significantly decreased 1-year post-TAVR. Furthermore, we showed that a higher baseline LVMI correlated with a larger improvement in GLS post-TAVR, explaining the late ongoing improvement in systolic function.

A notable portion of the patients included in the study had a history of coronary artery disease, with the majority undergoing coronary intervention over a year before TAVR. Only two patients (2.5% of the total sample) had coronary intervention performed during the TAVR procedure and had only a modest increase in GLS. In addition, GLS values, as well as ΔGLS, stratified by CAD status were comparable pre- and post-TAVR, as presented in Supplementary Figure 1 ^{(500.1KB, tif)} . This suggests that the observed increase in LV GLS was not influenced by recent or concurrent coronary interventions, further supporting the notion that the improvement in LV GLS was primarily attributable to the TAVR itself.

Our study also assessed RV function, which remained unchanged after TAVR. This indicates that the improvement in LV GLS observed in our findings was independent of any changes in RV function, highlighting that this improvement was primarily driven by TAVR itself.

In the current study, we found that 1 year after TAVR, baseline pulmonary hypertension is significantly reversible in most patients. The mean SPAP reduction was 4.2 mmHg which can be attributed to several hemodynamic improvements; by relieving the obstruction caused by the stenotic aortic valve, TAVR significantly reduces LV afterload and improves LV diastolic function, thereby lowering the pressure transmitted backward to the left atrium and pulmonary circulation. Over time, these changes may also promote partial remodeling of the pulmonary vasculature, reversing some of the chronic adaptations to elevated pulmonary venous pressures and further lowering SPAP.[27] These findings were consistent with Alushi et al. where SPAP continued to improve even after 1 year of follow-up.[27]

We also found that patients with lower GLS and LVEF levels at baseline experienced greater improvements in GLS following TAVR, as shown in Figure 3. This indicates that patients with baseline depression in systolic function benefit the most from the procedure, a finding consistent with observations from other studies.[28]

Figure 3.

Correlation between baseline global longitudinal strain (GLS) and improvement in GLS posttranscatheter aortic valve replacement. GLS = Global longitudinal strain

We conducted a subgroup analysis to compare changes in GLS between patients with normal baseline GLS (≤−18) and abnormal baseline GLS (>−18).[29] The results are summarized in Supplementary Table 1. Both ΔGLS and percentage change in GLS differ significantly between the two groups (P < 0.001). Patients in the abnormal GLS group had a significantly greater improvement in GLS compared to the normal GLS group, both in absolute change (−4.08 ± 3.47 vs. −1.13 ± 1.79, P < 0.001) and % change (49.7 ± 74.6% vs. 5.99 ± 9.28%, P = 0.002). Therefore, patients with abnormal baseline GLS demonstrate greater responsiveness to TAVI as reflected by a more pronounced improvement in myocardial function following the intervention. This also suggests that a baseline GLS of −18% as threshold is an effective predictor for more important changes in GLS following TAVR.

Supplementary Table 1.

Comparison of global longitudinal strain change between normal and abnormal baseline global longitudinal strain groups

	Paired t-test		Independent t-test (Welch)
	Normal GLS (n=45)	Abnormal GLS (n=35)	Comparison of delta GLS	Comparison of percentage change
ΔGLS (mean±SD)	−1.13±1.79	−4.08±3.47	NA	NA
Percentage change ΔGLS	5.99±9.28%	49.7±74.6%	NA	NA
t	−4.24	−6.85	−4.52	−3.40
df	44	33	46.14	33.77
P	0.00011	8.13×10−8	4.29×10−5	0.00176
Mean difference	−1.13	−4.08	Abnormal > normal	Abnormal > normal
95% CI	−1.67–−0.59	−5.29–−2.87	−4.26–−1.64	−69.89–−17.56

GLS=Global longitudinal strain, CI=Confidence interval, NA=Not available, SD=Standard deviation

An illustrative example from our study highlights the importance of GLS in detecting improvements in LV function post-TAVR. A patient with a baseline GLS of −17.2% and EF of 55%–59% demonstrated a significant improvement in GLS to −20.2% at 1-year post-TAVR, while EF showed a modest increase to 60%–64%. This case underscores the value of GLS as a more sensitive marker of myocardial recovery, capturing subclinical changes that may not be fully reflected by EF. Such findings emphasize the utility of GLS in evaluating the benefits of TAVR and guiding patient management.

In light of these findings, a low GLS in patients with severe AS can serve as an indicator for performing an early AVR, as it indicates an early decline in LV performance that can potentially be reversed with prompt intervention. However, further studies with larger sample sizes and long-term follow-up are needed to validate and confirm this statement.

CONCLUSION

GLS improves significantly 1 year after TAVR, indicating an overall enhancement of LV performance. The degree of improvement in GLS correlates with baseline LVMI and systolic function. LV strain analysis post-TAVR is more effective than conventional echocardiography in detecting subtle improvements in systolic myocardial function.

Limitations

The relatively low number of patients included in the final analysis is a limitation of this study. Nevertheless, the sample size was sufficient to achieve statistically significant results. The small sample size limited our ability to analyze the impact of post-TAVR complications on LV GLS and survival outcomes. These events were infrequent in our cohort, precluding meaningful conclusions. The study population was heterogeneous with respect to comorbidities, which is reflective of the typical clinical scenario in which TAVR is indicated, as patients of advanced age often present with multiple comorbid conditions such as hypertension and coronary artery disease. In addition, our analysis focused exclusively on longitudinal strain, which is the most clinically relevant and widely used measure of strain. However, other strain analyses, such as radial and circumferential strain, also exist and can provide valuable insights, particularly in research settings. Furthermore, while we included only global strain in our study, our strain calculations also encompassed segmental (17-segment) strain analysis, which was not reported.

Ethical statement

The study was approved by the institutional Ethics Committee of the American University of Beirut IRB ID: BIO-2023-0142.

Conflicts of interest

There are no conflicts of interest.

Supplementary Figure 1

Global longitudinal strain values stratified by coronary artery disease status. GLS = Global longitudinal strain, CAD = Coronary artery disease

Funding Statement

Nil.