Incremental prognostic value of left ventricular and left atrial strains in moderate aortic stenosis

Abstract

Aims: Patients with moderate aortic stenosis (AS) show a poor prognosis if they have high-risk features. We investigated herein the incremental prognostic value of left ventricular (LV) and left atrial (LA) strain in patients with moderate AS.

Methods and results: In a cohort of 923 patients with moderate AS (median age 74 years, men 55%, aortic valve area 1.18 [interquartile range (IQR) 1.08-1.30] cm2, mean pressure gradient 25 [IQR 23-30] mmHg), the LV global longitudinal strain (LV-GLS) and LA reservoir strain (LARS) were measured using speckle-tracking echocardiography. Absolute values of myocardial strain were used. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization. During a median of 5.9 years, the primary endpoint occurred in 186 patients (20.2%). The median LV-GLS and LARS were 17.7% (IQR 14.8-19.7%) and 24.5% (IQR 18.7-29.3%), respectively. LV-GLS [adjusted hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.87-0.97] and LARS (adjusted HR 0.97, 95% CI 0.95-0.99) were significant predictors of the primary outcome, independent of clinical and echocardiographic variables, including LV ejection fraction. Notably, the prognostic value of LV-GLS was stronger than that of LARS, remaining significant after further adjustment for LARS. LV-GLS < 17% and LARS < 22% were identified as optimal cut-offs for the primary outcome. Patients with both reduced LV-GLS and LARS had the worst outcomes (log-rank P < 0.001). LV-GLS < 17% and LARS < 22% had incremental prognostic values on top of other clinical and echocardiographic variables.

Conclusion: In moderate AS, reduced LV-GLS and LARS have incremental prognostic values and can refine risk stratification to identify high-risk patients.

Keywords: aortic stenosis; atrial function; echocardiography; myocardial deformation; ventricular function.