title: Myocardial strain and symptom severity in severe aortic stenosis: insights from cardiovascular magnetic resonance.
abstract: BACKGROUND
  Symptomatic severe aortic stenosis (AS) is a class I indication for replacement in patients when left ventricular ejection fraction (LVEF) is preserved. However, symptom reporting is often equivocal and decision making can be challenging. We aimed to quantify myocardial deformation using cardiovascular magnetic resonance (CMR) in patients classified by symptom severity.
  
  
  METHODS
  Forty-two patients with severe AS referred to heart valve clinic were studied using tagged CMR imaging. All had preserved LVEF. Patients were grouped by symptoms as either "none/mild" (n=21, NYHA class I, II) or "significant" (n=21, NYHA class III, IV, angina, syncope) but were comparable for age (72.8±5.4vs. 71.0±6.8 years old, P=0.345), surgical risk (EuroSCORE II: 1.90±1.7vs. 1.31±0.4, P=0.302) and haemodynamics (peak aortic gradient: 55.1±20.8vs. 50.4±15.6, P=0.450). Thirteen controls matched in age and LVEF were also studied. LV circumferential strain was calculated using inTag©software and longitudinal strain using feature tracking analysis.
  
  
  RESULTS
  Compared to healthy controls, patients with severe AS had significantly worse longitudinal and circumferential strain, regardless of symptom status. Patients with "significant" symptoms had significantly worse peak longitudinal systolic strain rates (-83.352±24.802%/svs. -106.301±43.276%/s, P=0.048) than those with "no/mild" symptoms, with comparable peak longitudinal strain (PLS), peak circumferential strain and systolic and diastolic strain rates.
  
  
  CONCLUSIONS
  Patients with severe AS who have no or only mild symptoms exhibit comparable reduction in circumferential and longitudinal fibre function to those with significant symptoms, in whom AVR is clearly indicated. Given these findings of equivalent subclinical dysfunction, reportedly borderline symptoms should be handled cautiously to avoid potentially adverse delays in intervention.
authors.affiliation: Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: Tarique
authors.initials: T
authors.lastname: Al Musa
authors.affiliation: Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: Akhlaque
authors.initials: A
authors.lastname: Uddin
authors.affiliation: Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: Peter P
authors.initials: PP
authors.lastname: Swoboda
authors.affiliation: Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: Pankaj
authors.initials: P
authors.lastname: Garg
authors.affiliation: Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Fairbairn
authors.affiliation: Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: Laura E
authors.initials: LE
authors.lastname: Dobson
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Glenfield General Hospital, Leicester, UK;; the National Institute of Health Research (NIHR), Cardiovascular Biomedical Research Unit, Glenfield General Hospital, Leicester, UK.
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Steadman
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Glenfield General Hospital, Leicester, UK;; the National Institute of Health Research (NIHR), Cardiovascular Biomedical Research Unit, Glenfield General Hospital, Leicester, UK.
authors.forename: Anvesha
authors.initials: A
authors.lastname: Singh
authors.affiliation: Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: Bara
authors.initials: B
authors.lastname: Erhayiem
authors.affiliation: Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK;; Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK.
authors.forename: Sven
authors.initials: S
authors.lastname: Plein
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Glenfield General Hospital, Leicester, UK;; the National Institute of Health Research (NIHR), Cardiovascular Biomedical Research Unit, Glenfield General Hospital, Leicester, UK.
authors.forename: Gerald P
authors.initials: GP
authors.lastname: McCann
authors.affiliation: Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK;; Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK.
authors.forename: John P
authors.initials: JP
authors.lastname: Greenwood
keywords: Aortic stenosis (AS); cardiovascular MRI; feature tracking; myocardial tissue tagging