Original Article| Volume 36, ISSUE 12, P4305-4312, December 2022

Incremental Prognostic Value of Left Ventricular Longitudinal Strain Over Ejection Fraction in Coronary Artery Bypass Grafting

Published:August 19, 2022DOI:


      To evaluate the incremental prognostic value of longitudinal strain over left ventricular ejection fraction (LVEF) after coronary artery bypass grafting (CABG).


      Retrospective cohort study.


      Single tertiary-care center.


      Patients underwent isolated CABG between January 2014 and December 2019.



      Measurements and Main Results

      There were 999 patients (median age, 65 years, 23.5% female) categorized into 3 groups according to their left ventricular (LV) systolic function status: pEF/pS (preserved LVEF and preserved longitudinal strain, n = 490), pEF/iS (preserved LVEF and impaired longitudinal strain, n = 186), and rEF (reduced LVEF, n = 323). During a median follow-up of 2.7 years, 86 (8.6%) patients had died. The 5-year survival significantly differed in patients with preserved LVEF according to the strain status (pEF/pS v pEF/iS, 90.0% v 84.6%; p = 0.002). After adjusting for potential confounders, the pEF/iS group (adjusted hazard ratio [HR], 2.17; 95% CI, 1.10-4.28; p = 0.03) and the rEF group (adjusted HR, 2.96; 95% CI, 1.46-6.00; p = 0.003) had significantly higher risks for all-cause death compared with the pEF/pS group. The addition of longitudinal strain to LVEF in the prediction model significantly improved its performance (global chi-squared, 105.2 v 110.2; p = 0.03).


      Left ventricular longitudinal strain could differentiate the prognosis after CABG in patients with preserved LVEF and provide significant incremental prognostic value to LVEF.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Soliman Hamad MA
        • van Straten AHM
        • Schönberger JPAM
        • et al.
        Preoperative ejection fraction as a predictor of survival after coronary artery bypass grafting: Comparison with a matched general population.
        J Cardiothorac Surg. 2010; 5: 1-8
        • Ahmed WA
        • Tully PJ
        • Baker RA
        • et al.
        Survival after isolated coronary artery bypass grafting in patients with severe left ventricular dysfunction.
        Ann Thorac Surg. 2009; 87: 1106-1112
        • Appoo J
        • Norris C
        • Merali S
        • et al.
        Long-term outcome of isolated coronary artery bypass surgery in patients with severe left ventricular dysfunction.
        Circulation. 2004; 110: II13-II17
        • Voigt JU
        • Cvijic M.
        2- and 3-dimensional myocardial strain in cardiac health and disease.
        JACC Cardiovasc Imaging. 2019; 12: 1849-1863
        • Cikes M
        • Solomon SD.
        Beyond ejection fraction: An integrative approach for assessment of cardiac structure and function in heart failure.
        Eur Heart J. 2016; 37: 1642-1650
        • MacRon L
        • Lairez O
        • Nahum J
        • et al.
        Impact of acoustic window on accuracy of longitudinal global strain: A comparison study to cardiac magnetic resonance.
        Eur J Echocardiogr. 2011; 12: 394-399
        • Biering-Sorensen T
        • Biering-Sorensen SR
        • Olsen FJ
        • et al.
        Global longitudinal strain by echocardiography predicts long-term risk of cardiovascular morbidity and mortality in a low-risk general population: The Copenhagen city heart study.
        Circ Cardiovasc Imaging. 2017; 10e005521
        • Biering-Sørensen T
        • Hoffmann S
        • Mogelvang R
        • et al.
        Myocardial strain analysis by 2-dimensional speckle tracking echocardiography improves diagnostics of coronary artery stenosis in stable angina pectoris.
        Circ Cardiovasc Imaging. 2014; 7: 58-65
        • Dahl JS
        • Videbæk L
        • Poulsen MK
        • et al.
        Global strain in severe aortic valve stenosis relation to clinical outcome after aortic valve replacement.
        Circ Cardiovasc Imaging. 2012; 5: 613-620
        • Alashi A
        • Khullar T
        • Mentias A
        • et al.
        Long-term outcomes after aortic valve surgery in patients with asymptomatic chronic aortic regurgitation and preserved LVEF: Impact of baseline and follow-up global longitudinal strain.
        JACC Cardiovasc Imaging. 2020; 13: 12-21
        • Hiemstra YL
        • Tomsic A
        • van Wijngaarden SE
        • et al.
        Prognostic value of global longitudinal strain and etiology after surgery for primary mitral regurgitation.
        JACC Cardiovasc Imaging. 2020; 13: 577-585
        • Gozdzik A
        • Letachowicz K
        • Grajek BB
        • et al.
        Application of strain and other echocardiographic parameters in the evaluation of early and long-term clinical outcomes after cardiac surgery revascularization.
        BMC Cardiovasc Disord. 2019; 19: 189
        • Olsen FJ
        • Lindberg S
        • Pedersen S
        • et al.
        Global longitudinal strain predicts cardiovascular events after coronary artery bypass grafting.
        Heart. 2021; 107: 814-821
        • Skaarup KG
        • Iversen A
        • Jørgensen PG
        • et al.
        Association between layer-specific global longitudinal strain and adverse outcomes following acute coronary syndrome.
        Eur Heart J Cardiovasc Imaging. 2018; 19: 1334-1342
        • Yang H
        • Negishi K
        • Wang Y
        • et al.
        Echocardiographic screening for non-ischaemic stage B heart failure in the community.
        Eur J Heart Fail. 2016; 18: 1331-1339
        • Sengeløv M
        • Jørgensen PG
        • Jensen JS
        • et al.
        Global longitudinal strain is a superior predictor of all-cause mortality in heart failure with reduced ejection fraction.
        JACC Cardiovasc Imaging. 2015; 8: 1351-1359
        • Bertini M
        • Ng ACT
        • Antoni ML
        • et al.
        Global longitudinal strain predicts long-term survival in patients with chronic ischemic cardiomyopathy.
        Circ Cardiovasc Imaging. 2012; 5: 383-391
        • Ersbøll M
        • Valeur N
        • Mogensen UM
        • et al.
        Prediction of all-cause mortality and heart failure admissions from global left ventricular longitudinal strain in patients with acute myocardial infarction and preserved left ventricular ejection fraction.
        J Am Coll Cardiol. 2013; 61: 2365-2373
        • Picard MH
        • Adams D
        • Bierig SM
        • et al.
        American Society of Echocardiography recommendations for quality echocardiography laboratory operations.
        J Am Soc Echocardiogr. 2011; 24: 1-10
        • Mitchell C
        • Rahko PS
        • Blauwet LA
        • et al.
        Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: Recommendations from the American Society of Echocardiography.
        J Am Soc Echocardiogr. 2019; 32: 1-64
        • Negishi K
        • Negishi T
        • Kurosawa K
        • et al.
        Practical guidance in echocardiographic assessment of global longitudinal strain.
        JACC Cardiovasc Imaging. 2015; 8: 489-492
        • Yancy CW
        • Jessup M
        • Bozkurt B
        • et al.
        2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.
        J Am Coll Cardiol. 2013; 62: e147-e239
        • Fortuni F
        • Bax JJ
        • Delgado V.
        Changing the paradigm in the management of valvular heart disease: In addition to left ventricular ejection fraction, focus on the myocardium.
        Circulation. 2021; 143: 209-211
        • Lacalzada J
        • de la Rosa A
        • Izquierdo MM
        • et al.
        Left ventricular global longitudinal systolic strain predicts adverse remodeling and subsequent cardiac events in patients with acute myocardial infarction treated with primary percutaneous coronary intervention.
        Int J Cardiovasc Imaging. 2015; 31: 575-584
        • Kim HM
        • Cho GY
        • Hwang IC
        • et al.
        Myocardial strain in prediction of outcomes after surgery for severe mitral regurgitation.
        JACC Cardiovasc Imaging. 2018; 11: 1235-1244
        • Cho EJ
        • Park SJ
        • Yun HR
        • et al.
        Predicting left ventricular dysfunction after surgery in patients with chronic mitral regurgitation: Assessment of myocardial deformation by 2-dimensional multilayer speckle tracking echocardiography.
        Korean Circ J. 2016; 46: 213-221
        • Salaun E
        • Casalta AC
        • Donal E
        • et al.
        Apical four-chamber longitudinal left ventricular strain in patients with aortic stenosis and preserved left ventricular ejection fraction: Analysis related with flow/gradient pattern and association with outcome.
        Eur Heart J Cardiovasc Imaging. 2018; 19: 868-878
        • Parma G
        • Florio L
        • Dayan V
        • et al.
        Apical 4-chamber longitudinal strain by vector velocity imaging: A promising predictor of left ventricular ejection fraction in healthy individuals.
        Rev Esp Cardiol (Engl Ed). 2015; 68: 351-352
        • Alenezi F
        • Ambrosy AP
        • Phelan M
        • et al.
        Left ventricular global longitudinal strain can reliably be measured from a single apical four-chamber view in patients with heart failure.
        J Am Soc Echocardiogr. 2019; 32: 317-318

      Linked Article

      • Prognosticating with Left Ventricular Global Longitudinal Strain – A New Opportunity for Cardiac Anesthesiologists
        Journal of Cardiothoracic and Vascular Anesthesia
        • Preview
          Left ventricular (LV) ejection fraction lacks sensitivity for identifying subclinical LV impairment from subendocardial longitudinal fiber disease, which may not affect LV ejection fraction measurements.1 LV strain is an echocardiographic measure of myocardial function capable of quantifying longitudinal, radial, and circumferential contractions.2 LV longitudinal strain is extensively used in the outpatient setting to predict outcomes in patients with valvular heart disease,3 cardiomyopathies,4 or undergoing anthracycline chemotherapy5 with a normal LV ejection fraction.
        • Full-Text
        • PDF