Article Text

Download PDFPDF
Original research
Left ventricular twist predicts mortality in severe aortic stenosis
  1. Ladina Erhart1,
  2. Thierry Donati1,
  3. Shehab Anwer1,
  4. Matthias Schindler1,
  5. Miriam Gremminger1,
  6. Melanie Renzulli2,
  7. Nazar Kuzo1,
  8. Anna L Walther1,
  9. Dominik Zürcher1,
  10. Sara Hosseini1,
  11. Matthias Eberhard2,
  12. Barbara E Stähli1,
  13. Felix C Tanner1
  1. 1 Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
  2. 2 Department of Radiology, University Hospital Zurich, Zurich, Switzerland
  1. Correspondence to Professor Felix C Tanner, Department of Cardiology, University Heart Center Zurich, Zurich CH-8091, Switzerland; felix.tanner{at}


Objective Left ventricular (LV) twist is a major component of ventricular mechanics reflecting the helical orientation of cardiac fibres and compensating for afterload mismatch. However, it is not known whether it determines outcome after transcatheter aortic valve implantation (TAVI). This study sought to investigate TAVI-induced short-term changes of LV twist and to define its role in outcome prediction.

Methods A total of 146 patients (median age 81.78 years, 50.7% male) undergoing TAVI for severe aortic stenosis were included. LV rotation and twist were determined by speckle tracking echocardiography within 3 months before and 2 weeks after TAVI. All-cause mortality at 2 years was defined as primary end point.

Results Patients who survived exhibited a higher apical peak systolic rotation (APSR) (p<0.001), twist (p=0.003) and torsion (p=0.019) pre-TAVI compared with those who died (n=22). Within 2 weeks after TAVI, APSR, twist and torsion decreased in patients who survived (all p<0.001), while no change occurred in those who died. Cox regression analysis showed an association of pre-TAVI APSR (HR 0.92, p=0.010), twist (HR 0.93, p=0.018) and torsion (HR 0.68, p=0.040) with all-cause mortality and an even stronger association of the respective changes after TAVI (∆APSR: HR 1.15, p<0.001; ∆twist: HR 1.14, p<0.001; ∆torsion: HR 2.53, p<0.001). All the parameters determined outcome independently of global longitudinal strain (GLS) and LV ejection fraction (LVEF).

Conclusion APSR, twist and torsion pre-TAVI as well as their change within 2 weeks after TAVI predict 2-year all-cause mortality after TAVI, adding incremental prognostic value to LVEF and GLS.

  • aortic stenosis
  • transcatheter aortic valve replacement

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Statistics from

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

View Full Text


  • Twitter @shehabanwer

  • LE and TD contributed equally.

  • Contributors All authors were involved in the design of the study under supervision of FCT. SA performed offline strain analyses, MG performed additional offline strain analyses for the evaluation of interobserver agreement. LE collected clinical baseline and follow-up data about the included patients together with TD, ALW and DZ. LE carried out the statistical analyses together with MS. LE and TD summarised the pre-existing literature. LE wrote the first complete draft of the manuscript under supervision of FCT. All other authors contributed to further drafts and approved the final manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.