title: Prognostic value of global longitudinal strain in paradoxical low-flow, low-gradient severe aortic stenosis with preserved ejection fraction.
abstract: BACKGROUND
  To assess whether global longitudinal strain (GLS) can discriminate high-risk patients with adverse outcome in paradoxical low-flow, low-gradient (LFLPG) severe aortic stenosis (AS). METHODS AND RESULTS: We enrolled 204 patients with severe AS (indexed aortic valve area [iAVA] <0.6 cm(2)/m(2)) and preserved left ventricular ejection fraction (LVEF >50%). Patients were divided into 4 groups according to flow state (stroke volume index < or > 35 ml/m(2)) and mean pressure gradient (< or > 40 mmHg). LV GLS was measured by 2-dimensional speckle-tracking analysis. The primary endpoint consisted of major cardiovascular events, including aortic valve replacement. During a mean 399-day follow-up, 51 (25%) patients met the primary endpoint. Among the 98 LFLPG AS patients, GLS was significantly reduced in patients with any event (-15.6±4.5% vs. -19.4±3.6%, P=0.002). Using receiver-operating characteristic analysis, we classified LFLPG AS patients as impaired GLS (GLS ≥-17%, n=24) or preserved GLS (GLS <-17%, n=74). The impaired GLS group had smaller iAVA, higher LV mass index, higher E/E', and lower overall 2-year event-free survival (57% vs. 97%; P<0.001) than the preserved GLS group.
  
  
  CONCLUSIONS
  Longitudinal function was severely impaired in patients with LFLPG AS and they had poor prognosis. GLS could stratify the high-risk group for future adverse outcomes. Patients with paradoxical LFLPG AS comprised a mixed group with different LV mechanical properties associated with different prognoses.
authors.affiliation: Cardiovascular Division, Graduate School of Comprehensive Human Sciences, University of Tsukuba.
authors.forename: Kimi
authors.initials: K
authors.lastname: Sato
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Seo
authors.forename: Tomoko
authors.initials: T
authors.lastname: Ishizu
authors.forename: Masaaki
authors.initials: M
authors.lastname: Takeuchi
authors.forename: Masaki
authors.initials: M
authors.lastname: Izumo
authors.forename: Kengo
authors.initials: K
authors.lastname: Suzuki
authors.forename: Eiji
authors.initials: E
authors.lastname: Yamashita
authors.forename: Shigeru
authors.initials: S
authors.lastname: Oshima
authors.forename: Yoshihiro J
authors.initials: YJ
authors.lastname: Akashi
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Otsuji
authors.forename: Kazutaka
authors.initials: K
authors.lastname: Aonuma
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging* / Q000401:mortality* / Q000503:physiopathology*; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D011237:Predictive Value of Tests; D013318:Stroke Volume; D015996:Survival Rate; D014463:Ultrasonography