title: Incremental prognostic value of left ventricular global longitudinal strain in patients with aortic stenosis and preserved ejection fraction.
abstract: BACKGROUND
  We sought to assess the utility of left ventricular global longitudinal strain (LV-GLS) in predicting mortality in moderate to severe and paradoxical severe aortic stenosis (AS) patients with preserved ejection fraction.
  
  
  RESULTS
  We studied 395 AS patients (70 ± 14 years, 57% men) with aortic valve area <1.3 cm(2) evaluated between January to June 2008 (excluding severe other valve disease and LV ejection fraction <50%). Clinical and echocardiographic data were recorded. LV-GLS was analyzed using Velocity Vector Imaging. AS patients were classified as (a) moderate-severe (n=93; aortic valve area, 1.1-1.3 cm(2)), (b) standard severe (n=161; aortic valve area, ≤1 cm(2); mean gradient ≥40 mm Hg), and (c) paradoxical severe (n=141; aortic valve area, ≤1 cm2 and mean gradient <40 mm Hg). Additive Euroscore was 7 ± 3. The association of LV-GLS with all-cause mortality was assessed after risk-adjustment using Cox proportional hazards models. Median LV-GLS was -14.8% (interquartile range, -17.2%, -12.1%). At 4.4±1.4 years, there were 92 (23%) deaths. On multivariable Cox analysis, additive Euroscore (hazard ratio, 1.19; 1.13-1.27; P<0.001), New York Heart Association class (hazard ratio, 1.44; 1.11-1.87; P<0.001), AV surgery with time-dependent covariate analysis (hazard ratio, 0.29; 0.19-0.45; P<0.001), and LV-GLS (hazard ratio, 1.05; 1.03-1.07; P<0.001) were independent predictors of mortality. LV-GLS <-12.1% (4th quartile) was associated with significantly reduced survival. Addition of LV-GLS to clinical parameters (additive Euroscore+New York Heart Association class) led to significant improvement in prediction of mortality (χ(2) increased from 48 to 58; P<0.01).
  
  
  CONCLUSIONS
  LV-GLS independently predicts mortality in moderate-severe and severe AS patients with preserved LV ejection fraction, providing incremental prognostic utility, in addition to standard clinical and echocardiographic parameters.
authors.affiliation: From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Kenya
authors.initials: K
authors.lastname: Kusunose
authors.affiliation: From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Andrew
authors.initials: A
authors.lastname: Goodman
authors.affiliation: From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Roosha
authors.initials: R
authors.lastname: Parikh
authors.affiliation: From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Tyler
authors.initials: T
authors.lastname: Barr
authors.affiliation: From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Shikhar
authors.initials: S
authors.lastname: Agarwal
authors.affiliation: From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Zoran B
authors.initials: ZB
authors.lastname: Popovic
authors.affiliation: From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Grimm
authors.affiliation: From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Brian P
authors.initials: BP
authors.lastname: Griffin
authors.affiliation: From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH. desaim2@ccf.org.
authors.forename: Milind Y
authors.initials: MY
authors.lastname: Desai
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology*; D016009:Chi-Square Distribution; D018619:Echocardiography, Doppler, Pulsed; D005260:Female; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017711:Nonlinear Dynamics; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume; D013997:Time Factors; D016277:Ventricular Function, Left
keywords: aortic stenosis; outcomes