title: Usefulness of atrial function for risk stratification in asymptomatic severe aortic stenosis.
abstract: OBJECTIVE
  We aimed to evaluate the usefulness of left atrial (LA) mechanics and stiffness over global left ventricular (LV) longitudinal strain (GLS) for risk stratification in severe aortic stenosis (AS).
  
  
  METHODS
  From a cohort of 89 prospective asymptomatic patients with severe AS and normal LV ejection fraction, 82 (32 men, mean age 73±10 years) truly asymptomatic patients, scheduled after a negative exercise echocardiogram, were enrolled. Forty age- and gender-matched prospective, asymptomatic subjects served as controls. Predefined end points were the occurrence of symptoms (dyspnea, angina, syncope), and death during follow-up.
  
  
  RESULTS
  At study entry, patients had: impaired LV GLS (p=0.001), reduced LA reservoir (p<0.001), high LA stiffness (p<0.001), and increased valvulo-arterial impedance (p<0.001) compared to controls. During follow-up [16±14.9 months (ranging from 1 month to 4.2 years)], 53 patients (64.6%) reached one of the endpoints. Patients with events showed lower LV GLS (p>0.001), lower LA reservoir (p<0.001), and greater LA stiffness (p<0.001) than those asymptomatic. On univariate Cox regression analysis, LV GLS (p<0.001), LA reservoir (p<0.001), and LA stiffness (p=0.004) were strong predictors of adverse events. Kaplan-Meier curves showed that event-free survival was significantly higher in patients with a LV GLS ≥16.8% [p<0.001; area under the curve (AUC)=0.922; sensitivity=86%, specificity=80%], a LA reservoir ≥19.8% (p=0.001; AUC=0.860, sensitivity=71%, specificity=84%), and a LA stiffness <0.78 (p<0.001; AUC 0.819, sensitivity 70%, specificity 89%). On multivariate analysis, only LV GLS remained significantly associated with patients' prognosis (hazard ratio=1.49, 95% CI=1.11-2.01, p=0.008).
  
  
  CONCLUSIONS
  In asymptomatic patients with severe AS, an efficient cardiovascular system is based on an effective atrial-ventricular interplay. LA function assessment is useful for early identification of risk in these patients. LV GLS however was confirmed to be the best predictor of patients' outcome.
authors.affiliation: Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy.
authors.forename: Maria Chiara
authors.initials: MC
authors.lastname: Todaro
authors.affiliation: Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy.
authors.forename: Scipione
authors.initials: S
authors.lastname: Carerj
authors.affiliation: Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health, Milwaukee, WI, USA. Electronic address: publishing22@aurora.org.
authors.forename: Bijoy
authors.initials: B
authors.lastname: Khandheria
authors.affiliation: Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Cusmà-Piccione
authors.affiliation: Internal Medicine, Villa Sofia Hospital, Palermo, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: La Carrubba
authors.affiliation: Cardiology Unit, Azienda Ospedaliera "S Maria Degli Angeli", Pordenone, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Antonini-Canterin
authors.affiliation: Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy.
authors.forename: Pietro
authors.initials: P
authors.lastname: Pugliatti
authors.affiliation: Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy.
authors.forename: Vitantonio
authors.initials: V
authors.lastname: Di Bello
authors.affiliation: Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Oreto
authors.affiliation: Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Di Bella
authors.affiliation: Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy.
authors.forename: Concetta
authors.initials: C
authors.lastname: Zito
mesh_terms: D000368:Aged; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging*; D058070:Asymptomatic Diseases; D016279:Atrial Function, Left / Q000502:physiology*; D016022:Case-Control Studies; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D014463:Ultrasonography; D059289:Vascular Stiffness / Q000502:physiology*; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging*
keywords: Aortic stenosis; Left atrial stiffness; Left atrial strain; Speckle tracking echocardiography