Prognostic impact of right ventricular strain in isolated severe tricuspid regurgitation

Background

Right ventricular (RV) systolic function is determinant in the evaluation of patients with severe tricuspid regurgitation (TR). Timely detection of RV dysfunction with conventional 2D echocardiography is challenging. RV strain has emerged as an accurate and sensitive tool for evaluation of RV function with the capability of detecting subclinical RV dysfunction.

Purpose

This study was aimed to evaluate the prognostic value of RV strain parameters in consecutive stable patients with severe TR.

Methods

Consecutive patients in stable clinical status with at least severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic following a comprehensive clinical protocol were included. Patients with previous episodes of heart failure or scheduled for TV intervention were excluded. RV systolic function was measured with conventional echocardiographic indices (RV fractional area change [FAC], tricuspid annular plane systolic excursion [TAPSE], DTI S wave [`S]) and with Speckle-tracking echocardiography (STE) derived automatic peak global and free wall longitudinal strain (RV-GLS and RV-FWLS respectively) using the EPIQ system (Philips Medical Systems, Andover, Massachusetts). A combined endpoint of hospital admission due to heart failure (HF) or all-cause mortality was defined. The interobserver variability of RV strain was assessed in 20 randomly selected patients.

Results

A total of 176 patients were included in this study. Strain parameters detected higher percentage of RV dysfunction compared to conventional indices (figure 1). After a median follow-up of 28 months (IQR: 15–48 months), n=65 patients (37%) reached the combined endpoint. 65 (37%) were admitted for right heart failure and 8% of the population (n=14) died. Cumulative event-free survival was significantly worse in patients with impaired RV-GLS and RV-FWLS. Conventional indices of RV systolic function were not associated with outcomes (p>0.05 for all). In a multivariable analysis (in a model including NYHA class, BNP values, biplane VC, RV end-diastolic area, and RV-FWLS), RV-FWLS was an independent predictors of heart failure and CV mortality (figure 1 and 2; LR χ2: 40.2, p<0.001). Inter-observer agreements for RV strain values were high (intraclass correlation coefficient for RV-GLS and RV-FWLS, r=0.96 and r=0.98 respectively)

Conclusion

Clinical outcomes demonstrate that RV strain parameters are superior to conventional indices of RV function in patients with isolated ≥ severe TR and absence of previous episodes of heart failure. Among all parameters of RV function, RV-FWLS is the strongest independent predictor of mortality and HF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto Carlos III

Clinical utility and prognostic value of right atrial function in severe tricuspid regurgitation. One more piece of the puzzle

Background

Optimal management of severe tricuspid regurgitation (TR) remains controversial. While right ventricular systolic function is an established prognostic marker of outcomes, the potential role of right atrial (RA) function is unknown.

Purpose

This study was aimed to describe RA function by 2D speckle tracking echocardiography (STE) in severe TR and to evaluate its potential association with cardiovascular outcomes

Methods

Consecutive patients with at least severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic following a comprehensive clinical protocol were included. Consecutive control subjects and patients with permanent atrial fibrillation (AF) were included for comparison. RA function was measured with 2D-STE and 3 components of RA function were calculated: reservoir (RASr), conduit (RAScd) and contractile (RASct) RA values using an automatic 2D strain analytical software (AutoStrain, Philips Medical Systems the EPIQ system, Figure 1). A combined endpoint of hospital admission due to heart failure (HF) or all-cause mortality was defined. The interobserver variability of RA strain was assessed in 30 randomly selected subjects (20 TR+5 AF+5 controls).

Results

A total of 176 patients with severe TR, 20 AF patients and 20 controls subjects were included in this study. Patients with at least severe TR showed lower RASr and RAScd compared to controls and to AF patients (Figure 1 and Table 1, p<0.05). After a median follow-up of 28 months (IQR: 15–48 months), n=65 patients with severe TR (37%) reached the combined endpoint. 65 (37%) were admitted for right heart failure and 8% of the population (n=14) died. Patients with events showed lower values of RASr and RAScd (p<0.01 for both). Between both parameters RASr was more strongly associated with outcomes compared to RAScd (AUC 0.74 vs. 0.65, p<0.01). RASr was an independent predictor of heart failure and all cause mortality adjusted by additional imaging prognostic parameters in a multivariable analysis (biplane vena contracta, RV end-diastolic area, and RV-free wall longitudinal strain [LR χ2: 49.7, p<0.001]). RA area or volume was not associated with outcomes. A cut-off value of RASr of <9.4% held the best accuracy to predict outcomes (adjusted HR 3.2 (1.81–5.84), p<0.001, Figure 1). Inter-observer agreements for RA strain values across the whole cohort were high (intraclass correlation coefficient for RASr, RAScd and RASct, r=0.95, r=0.86, r=0,92 respectively)

Conclusions

Evaluation of RA function by 2D-STE is feasible, reproducible and is an independent predictor of heart failure and all-cause mortality in patients with at least severe TR.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): INSTITUTO CARLOS III

The 4A classification for patients with tricuspid regurgitation

Background

Significant Tricuspid Regurgitation (TR) is associated with increased morbi-mortality. Clinical evaluation of TR patients is challenging.

Purpose

To establish a new clinical classification specific for patients with TR, the 4A classification, and evaluate its performance on prognosis.

Methods

Consecutive patients with isolated at least severe TR and absence of episodes of heart failure (HF) evaluated in the Heart Valve Clinic were included. Signs and symptoms of Asthenia, Ankle swelling, Abdominal pain or distention and/or Anorexia where registered, follow up was performed every 6 months. 4A classification ranged from A0 (no A) to A4 (three or four A's present). A combined endpoint of hospital admission due to right HF and cardiovascular mortality was defined.

Results

135 patients with significant TR between 2016 and 2021 were included (69% females, mean age was 78±7 years). During a median follow-up of 26 months (IQR: 10–41 months), n=53 patients (39%) reached the combined endpoint. 52 (38%) admitted for heart failure and 11% (n=15) died. At baseline 94% of patients were in NYHA I or II whereas 24% presented A2 or A3. The presence of A2 or A3 showed a high incidence of events (figure). The change in 4A class and GGT remained independent predictor of HF and cardiovascular mortality (adjusted HR per unit of change of 4A class 1.95 [1.37–2.77], p<0.001)

Conclusions

For the first time, we show the use of a new clinical classification, specific for patients with TR based on signs and symptoms of right HF that is prognostic of events.

Funding Acknowledgement

Type of funding sources: None.

STREI: a new index of right heart function in isolated severe tricuspid regurgitation by Speckle tracking Echocardiography

Background

Right ventricular (RV) performance is key in the management of patients with severe tricuspid regurgitation (TR); detection of RV dysfunction is crucial to identify on time patients that benefit from valve intervention. Conventional parameters of RV function by 2D echocardiography are influenced by changes on preload conditions and can remain unaffected until late stages of the disease. The right atrium (RA) has an important role in modulating RV filling and RA performance is impaired in severe TR. Potentially, an index that combines RV and RA function may reflect a broader view of the effects of severe TR in right heart function.

Purpose

1) to evaluate the clinical utility of combining RV and RA strain for prediction of CV outcomes and 2) to design a novel index by Speckle-tracking echocardiography (STREI index) that integrates RA and RV information

Methods

Consecutive patients with at least severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic following a comprehensive clinical protocol were included. Consecutive control subjects and patients with permanent atrial fibrillation (AF) were included for comparison. Reservoir RA strain (RASr) and RV-free wall longitudinal strain (RV-FWLS) analysis were performed using novel, automated 2D strain analytical software (AutoStrain, Philips Medical Systems the EPIQ system, Figure 1). Novel STREI index was calculated with the formula: [2 × RV-FWLS] + RASr in absolute numbers.

A combined endpoint of hospital admission due to heart failure (HF) or all-cause mortality was defined. The interobserver variability of RA strain was assessed in 30 randomly selected subjects (20 TR+5 AF+5 controls).

Results

A total of 176 patients with severe TR, 20 AF patients and 20 controls subjects were included in this study. Patients with TR showed lower STREI values compared to controls and to AF patients (TR vs. controls vs. AF: 55±18 vs. 116±12 vs. 70±13, p<0,001). After a median follow-up of 28 months (IQR: 15–48 months), n=65 patients with severe TR (37%) reached the combined endpoint. Patients with both abnormal strains (abnormal RV-FWLS and abnormal RASr strain) showed a significantly higher rate of events (Figure 2A). In a multivariable analysis, STREI index was an independent predictor of HF and mortality adjusted by vena contracta, RV end-diastolic area, NYHA class and BNP values (LR χ2: 46,1, p<0,001). A cut off value of STREI index <50% held the best accuracy to predict outcomes. An abnormal STREI index was associated with 6,1-fold increased risk of HF or death (HR 6,9 (3,9–12,3), p<0,001, Figure 2B) Inter-observer agreements for STREI values were high (intraclass correlation coefficient = 0,96).

Conclusion

STREI index is a feasible and reproducible new parameter of RV performance that independently predicts outcomes in patients with severe TR. Randomized studies should confirm its potential to identify those patients that benefit from earlier valve interventions.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto Carlos III

Severity of tricuspid regurgitation (TR) only based in echo parameters? The failure of guidelines. The 4A in patients with significant TR as a new clinical score to evaluate patients with TR

Background

Significant Tricuspid Regurgitation (TR) is associated with increased morbi-mortality. Symptoms due to TR are often insidious and not always characterized by dyspnea. Identification of symptoms and optimal timing for intervention is challenging and intervention is often preformed late. A more specific clinical classification focused on the detection of systemic congestion may help identify those who may benefit from an earlier intervention.

Purpose

To evaluate the prognostic impact of a new proposed “4A” clinical score: Asthenia, Ankle swelling, Abdominal pain or distention and/or Anorexia, in patients with significant TR.

Methods

Consecutive patients in stable clinical condition evaluated in the Heart Valve Clinic with significant TR (moderate to severe, severe, massive or torrential TR) were included. Signs and symptoms of Asthenia, Ankle swelling, Abdominal pain or distention and/or Anorexia (“4A score”) where registered, follow up was performed every 6 months. The 4A clinical score ranged from 0 (no A) to 4 (all four A's present). The difference in the 4A score between the first and last visit was determined. A combined endpoint of hospital admission due to right heart failure and cardiovascular mortality was defined.

Results

86 patients were included in this study (age 76±11 years, 70% female, 87% functional TR). At first visit, 92% were in NYHA class I or II and 77% had a 0 or 1 “4A score”. After a median follow-up of 24 months (IQR: 11–35 months), “4A score” was significantly impaired (score mean difference: 0.42±0.8) and only 59% remained with a 0 or 1 “4A score”. 32.6% of the patients (n=28) experienced the combined endpoint. The change in 4A score was a significant predictor of events (hazard ratio per unit 1.88 [1.22–2.88], p=0.004)

Conclusion

We demonstrate for the first time a new clinical score predictive of right heart failure and death in patients with significant TR.

Funding Acknowledgement

Type of funding sources: None.

Mortality and heart failure in patients with severe tricuspid regurgitation. Impact of RV volumes and function by CMR

Background and objectives

Right ventricle (RV) dilatation and dysfunction are established criteria for intervention in patients with significant tricuspid regurgitation (TR); however defined thresholds to support intervention are lacking. As a result the optimal timing for surgery in TR remains controversial and surgery is commonly undertaken at a late stage.

Purpose

To describe predictive cut-off values of RV size and function of poor prognosis in asymptomatic patients with significant TR.

Methods

Consecutive patients in stable clinical condition evaluated in the Heart Valve Clinic with significant TR (severe, massive or torrential TR) undergoing a Cardiac Magnetic Resonance (CMR) study were included. Conventional parameters of biventricular volume and function were assessed in all patients. A combined endpoint of hospital admission due to right heart failure and cardiovascular mortality was defined.

Results

75 patients were included in this study (age 75±8 years, 75% female, 91% functional TR). During a median follow-up of 3 years (IQR: 1.4–3.9 years), 39% of the patients (n=29) experienced the combined endpoint. After adjusting for age and LVEF in a multivariate Cox proportional model, RV-EDV and RVEF were independently associated with cardiovascular mortality and heart failure. Thresholds of RV-EDV ≥100 ml/m2, RV-ESV ≥40 ml/m2 and RVEF ≤58% held the best accuracy to predict outcomes (figure 1). Regression spline model for RVEF and outcomes are presented in the figure 2. They show that RV function negatively impacted event-free survival, with an increase in the HR spline function near the crossing value (red line, RVEF ≤58%). In multivariable analysis, following adjustment for age and LVEF, a value of RVEF ≤58% and RV-EDV ≥100 ml/m2, was associated with 2.29, and 3.91-fold increased risk of heart failure or cardiovascular death respectively (RVEF Hazard Ratio (HR): 2.29 [1.06–4.9], p=0.03, and RV-EDV HR: 3.91 [1.56–9.82], p=0.004).

Conclusion

RV size and function are crucial for determining optimal timing for TR intervention. For the first time, cut-off values of RV volume and function are defined in a cohort of consecutive patients based on outcome data. Proposed values provide a basis for prospective studies to establish definitive optimal surgical timing for severe TR.

Funding Acknowledgement

Type of funding sources: None. Figure 1. ROC and Cox regressions analysisRegression spline curve

Prognostic value of right ventricular systolic function by speckle tracking echocardiography beyond conventional echocardiography in significant tricuspid regurgitation

Background

Right ventricular (RV) systolic function is determinant in the evaluation of patients with significant tricuspid regurgitation (TR). Timely detection of RV dysfunction with conventional 2D echocardiography is limited by the geometry and position of the RV. RV strain has emerged as an accurate and sensitive tool for evaluation of RV function with the capability of detect subclinical RV dysfunction

Purpose

This study was aimed to evaluate the prognostic value of RV strain in consecutive patients with significant TR, in comparison with conventional parameters of RV systolic function.

Methods

Consecutive patients in stable clinical status with significant TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic were included. RV systolic function was measured with conventional echocardiographic parameters (RV fractional area change [FAC], tricuspid annular plane systolic excursion [TAPSE]), DTI S wave (S') and with STE derived automatic peak global and free wall longitudinal strain (GLS, FW-LS respectively) using the EPIQ system (Philips Medical Systems, Andover, Massachusetts). A combined endpoint of hospital admission due to right heart failure or cardiovascular mortality was defined.

Results

A total of 130 patients were included (mean age was 75±17 years, 69% females, 93% in NYHA I/II). According to etiology, 14% were primary TR and 86% were functional (49% due to corrected left valve disease and 37% due to tricuspid annulus dilatation). Mean values of RV function parameters are shown in the table. During a mean follow up of 18±8 months, n=39 patients (30%) reached the combined endpoint. Patients with events showed impaired RV GLS and FW-LS. Both parameters were predictive of the combined endpoint (table 1). Conventional parameters of RV systolic function were not associated with outcomes (p>0.05 for all).

Conclusion

In patients with severe TR, RV strain values are superior to conventional parameters to detect RV dysfunction. Among different measurements of RV function, RV GLS and FW-LS were the only predictors of poor prognosis. These parameters should be included in the serial evaluation of these patients.

Funding Acknowledgement

Type of funding sources: None. RV parameters

Prognostic value of diastolic function parameters in significant aortic regurgitation. The role of the left atrial strain

Background

The management of patients with asymptomatic significant aortic regurgitation (sAR) is often challenging and appropriate timing of aortic valve surgery remains controversial. There are no strong indicators to recommend early surgery in patients with sAR, however delaying the time for the intervention could bring potential negative consequences, such as the risk of permanent left ventricular (LV) dysfunction. The prognostic value of diastolic parameters has been demonstrated in several cardiac diseases. In particular, left atrial (LA) function has been shown to be an important determinant of morbimortality.

Purpose

The purpose of this study was to analyze the prognostic significance of diastolic function parameters, included LA strain, in asymptomatic patients with sAR and to evaluate whether these parameters could help to identify patients at high risk of adverse events that could benefit from early cardiac surgery.

Methods

From February 2013 to November 2019 consecutive asymptomatic patients with chronic sAR evaluated in the Heart Valve Clinic with a comprehensive transthoracic echocardiogram (TTE) were included. Combined clinical endpoint included hospital admission due to heart failure, cardiovascular mortality, or indication for aortic valve surgery.

Results

A total of 126 patients were included. During a mean follow up of 33±19 month, 25 (19.8%) patients reached the combined end-point.

In a sub-group of 57 patients with TTE performed in the Philips stations, LA auto-strain analysis was obtained (figure 1).

Univariate analysis showed that LV volumes, LVEF, E wave, E/e' ratio, LA volume and LA reservoir strain (LASr) were significant predictors of events, whereas LA diameter, and LV diastolic diameters were not. Multivariate model 1 that tested all echocardiographic variables statistically significant in the univariate model showed that the LVEDV and E/e' ratio, were significant predictors of events. In the subgroup of patients with LA auto-strain analyzed, a second multivariable model was built, including the previous significant variables for the first model (LVEDV and E/e' ratio), as well as the LA volume and LASr. It showed that LVEDV and LASr were the most significant predictors of cardiovascular events (figure 2).

Conclusions

In this population of asymptomatic patients with sAR and normal LV systolic function, baseline diastolic parameters were prognostic markers of cardiovascular events; among them, LA reservoir strain played a strong independent predictor role. In addition, our results also showed that LV volumes had greater prognostic value that LV diameters in patients with asymptomatic sAR.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Prognostic impact of different parameters of right ventricular systolic function in patients with significant tricuspid regurgitation. A cardiac magnetic resonance study

Background

Right ventricle (RV) dysfunction represent an established criteria for intervention in patients with significant tricuspid regurgitation (TR). RV ejection fraction (RVEF) by Cardiac Magnetic Resonance (CMR) is considered the gold standard of RV function; however it is influenced by changes of preload conditions and may remain unaffected until late stages in severe TR. Novel measures of RV function such as RV longitudinal shortening (RV-LS) and effective RV ejection fraction (eRVEF) may be earlier markers of RV dysfunction.

Purpose

To compare the prognostic impact of conventional and novel parameters of RV systolic function.

Methods

Consecutive patients in stable clinical condition evaluated in the Heart Valve Clinic with significant TR (severe, massive or torrential TR) undergoing a CMR study were included. In addition to conventional parameters of biventricular volume and function, RV-LS and eRVEF were assessed as novel parameters of RV function. RV-LS was assessed in the 4-chamber view by measuring the displacement of the tricuspid annulus during the cardiac cycle. The length between the epicardial border of the LV apex and the middle of a line connecting the origins of the tricuspid valve leaflets was measured in both end-systole and end-diastole. Effective RVEF (eRVEF) is a measure of RV global systolic function but corrected by TR volume. Both formulas are represented in figure 1. A combined endpoint of hospital admission due to right heart failure and cardiovascular mortality was defined

Results

75 patients were included in this study (age 75±8 years, 75% female, 91% functional TR) During a median follow-up of 3 years (IQR: 1.4–3.9 years), 39% of the patients (n=29) experienced the combined endpoint. RV-LS and eRVEF identified higher rates of RV dysfunction than RVEF. RV-LS of ≥−14% and eRVEF of ≤34% were associated with impaired prognosis (figure 2). After adjustment of age and LVEF, both eRVEF (adjusted HR per abnormal value: 5.29 95% CI, [2.25–12.4]) and RV-LS (adjusted HR per abnormal value: 3.46, 95% CI, [1.13–9.17]) were significantly associated with outcomes. Among all parameters of RV function, eRVEF was the strongest predictor of outcomes, incremental to RVEF (Δ C-statistic 0.139 [0.040–0.237], p=0.005).

Conclusion

RV function is crucial for determining optimal timing for TR intervention. RV-LS and eRVEF identify higher rates of RV dysfunction beyond RVEF. Among all measures of RV function, eRVEF held the strongest association with outcome, incremental to RVEF.

Funding Acknowledgement

Type of funding sources: None. Figure 1. RV-LS and eRVEF calculationFigure 2. Kaplan Meier Curves

Mortality and heart failure in patients with severe tricuspid regurgitation. Risk stratification based on TR severity by CMR

Background

Tricuspid regurgitation (TR) is related to poor prognosis independently of the etiology. A new scale classification has been proposed to better characterize the grading of more than severe TR. Massive and torrential TR seem to have worse prognosis based on echocardiographic studies.

Purpose

To stratify patients' risk based on TR severity by CMR

Methods

Consecutive patients in stable clinical condition evaluated in the Heart Valve Clinic with significant TR (severe, massive or torrential TR) with a contemporaneous echo and CMR were included. TR severity was evaluated by vena contracta (VC) and ERO method, using EPIQ system (Phillip Medical system Andover, Massachusets) and by TR regurgitant fraction (TRF) using a 1.5 Tesla CMR Philips scanner. A combined endpoint of hospital admission due to right heart failure and cardiovascular mortality was defined.

Results

75 patients were included in this study (age 75±8 years, 75% female, 91% functional TR). According to echocardiography 75% were severe, 15% were massive and 10% were torrential TR. Patients with massive and torrential TR showed higher RV end-diastolic volume and lower RVEF. A TRF >50% held the best accuracy to define massive / torrential TR. During a median follow-up of 3 years (IQR: 1.4 – 3.9 years), 39% of the patients (n=29) experienced the combined endpoint. After adjusting for age and LVEF in a multivariate Cox proportional model, TRF was independently associated with cardiovascular mortality and heart failure (hazard ratio per 1%=1.05, [1.02–1.08], p<0.001). Patients were stratified in 3 groups according to TR severity. Patients with TRF ≤40% showed the lowest incidence of events and those with TRF ≥50% experienced the worse prognosis (log rank=0.001, figure)

Conclusion

Patients with massive/torrential TR are populations at higher risk of heart failure and mortality. Risk stratification strategies may identify the patients who benefit the most of intensive therapeutic treatments and intervention on the tricuspid valve. New classification scheme should be included in CMR grading scales.

Funding Acknowledgement

Type of funding sources: None. Kaplan Meier curve. Risk stratification

Prognostic value of serum biomarkers in patients with severe tricuspid regurgitation

Background

Significant tricuspid regurgitation (TR) is related to significant morbimortality. Given the lack of strong evidence, optimal timing for intervention remains controversial. Surgery is often performed late mainly because symptoms might go unnoticed until advance stages of the disease. The clinical impact of serum biomarkers evaluation in the serial evaluation of patients with significant TR is unknown.

Purpose

This study was aimed to evaluate the prognostic value of brain natriuretic peptide (BNP) and serum hepatic enzymes assessment in stable patients with significant tricuspid regurgitation

Methods

Consecutive patients in stable clinical status with significant TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic were included. Patients with previous episodes of heart failure were excluded. BNP levels and liver function enzymes were measured in all patients in their first visit. A combined endpoint of hospital admission due to right heart failure and cardiovascular (CV) mortality was defined.

Results

A total of 163 patients were included (mean age was 75±17 years, 69% females, 93% in NYHA I/II). According to etiology, 14% were primary TR and 86% were functional (49% due to corrected left valve disease and 37% due to tricuspid annulus dilatation). During a median follow up of 28 months (IQR: 15–49 months), n=59 patients (36%) reached the combined endpoint (n=12 patients died). Differences in BNP and liver function enzymes values in patients with or without events are shown in figure 1. BNP values and both cholestasis enzymes (alkaline phosphatase and gamma-glutamyl transferase) were independent predictors of the combined endpoints (Figure 2). In a multivariable Cox analysis (forward selection) in a model including BNP, alkaline phosphatase and gamma-glutamyl transferase, alkaline phosphatase remained as the sole independent predictor of outcome (HR: 1.01, [1.004–1.014], p<0.001).

Conclusion

Serum biomarkers held prognostic value in patients with significant TR. BNP values and colestasis enzymes are predictive of heart failure and CV death in stable patients with TR. Given the low clinical expression of the disease, these serum biomarkers should be considered in the serial evaluation of these patients.

Funding Acknowledgement

Type of funding sources: None. Comparison of serum biomarkersCox regression analysis

Prognostic value of right ventricular systolic function by speckle tracking echocardiography beyond conventional echocardiography in significant tricuspid regurgitation

Background

Right ventricular (RV) systolic function is determinant in the evaluation of patients with significant tricuspid regurgitation (TR). Timely detection of RV dysfunction with conventional 2D echocardiography is limited by the geometry and position of the RV. RV strain has emerged as an accurate and sensitive tool for evaluation of RV function with the capability of detect subclinical RV dysfunction

Purpose

This study was aimed to evaluate the prognostic value of RV strain in consecutive patients with significant TR, in comparison with conventional parameters of RV systolic function.

Methods

Consecutive patients in stable clinical status with significant TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic were included. RV systolic function was measured with conventional echocardiographic parameters (RV fractional area change [FAC], tricuspid annular plane systolic excursion [TAPSE]), DTI S wave ('S) and with STE derived automatic peak global and free wall longitudinal strain (GLS, FW-LS respectively) using the EPIQ system. A combined endpoint of hospital admission due to heart failure or cardiovascular mortality was defined.

Results

A total of 100 patients were included (mean age was 76±10 years, 65% females, 84% in NYHA I/II, 86% functional TR). Mean values of RV function parameters are shown in the table. During a mean follow up of 24±10 months, 24% of the patients reached the combined endpoint. Patients with events showed impaired RV GLS and FW-LS (p<0.01). Both parameters were predictive of the combined endpoint (table 1). Conventional parameters of RV systolic function were not associated with outcomes (p>0.05 for all).

Conclusion

In patients with severe TR, RV strain values are superior to conventional parameters to detect RV dysfunction. Among different measurements of RV function, RV GLS and FW-LS were the only predictors of poor prognosis. These parameters should be included in the serial evaluation of these patients.

Funding Acknowledgement

Type of funding source: None

Anatomical changes in tricuspid annulus and tricuspid regurgitation reduction after Cardioband implantation

Introduction

Isolated tricuspid regurgitation (TR) is an entity of high prevalence and associated with poor prognosis. Traditionally, treatment options have been limited because high surgery mortality. In this context, new percutaneous therapeutic options have appeared. The objective of this study is to describe the anatomical changes in tricuspid annulus (TA) and the immediate response in the TR severity after implantation of the Cardioband tricuspid system as well as the safety of the procedure.

Methods

Patients undergoing Cardioband implantation in our center where included. The diameter and area of the TA were measured by 2D and 3D transesophageal echocardiography (TEE) before and immediate after the implantation. TR severity was evaluated by the vena contracta width (VC) in 0 and 90 degrees by 2D TEE.

Results

Six patients (81.3 (79–85) years, 66.3% females) were included. The etiology of TR was dilatation of the ring in two cases, secondary to left valvulopathy in three cases and secondary to type III pulmonary hypertension in other case. Four patients presented basal severe TR, and two patients massive TR.

A significant reduction in TA diameters (reduction TA diameter 0°: 10.6 mm; 90°: 12.2 mm) and 3D TA area (4.5 mm2) was observed immediately after the procedure as well as a reduction in the VC width (reduction VC 0°: 4.8 mm; 90°: 3.9 mm). Table 1 shows the measurements before and after the procedure.

The success of the procedure was 84% (Five patients reduced one-degree TR severity, and one reduced two degrees TR severity). One patient was partial success because the complete implant of all anchors could not be performed. There was 0% intraprocedural mortality or major complications. There were two minor complications, one related to vascular access and the other related to an intra-atrial thrombus, both resolved.

Conclusions

The new percutaneous techniques to treat TR are a reality, and preliminary results seem to indicate that they are a safe and effective alternative, reducing the size of the ring and the severity of valvulopathy. Further studies and longer clinical follow-up will lead to the generalization of these new techniques.

Funding Acknowledgement

Type of funding source: None

Is Isolated tricuspid regurgitation different from functional tricuspid regurgitation?

Introduction

Isolated tricuspid regurgitation (TR) prevalence is increasing in the last decades. Its presence is associated with a worse prognosis when EROA is >40 mm2. Because of high surgery risk and increasing incidence, isolated TR is a challenge in modern cardiology.

Purpose

To evaluate the prevalence and characteristics of isolated TR compared to other TR aetiologies in a large cohort of patients.

Methods

Prospective study where consecutive patients undergoing an echocardiographic study within a three-month period were included. All studies with at least moderate TR were selected. Isolated TR was defined as TR with no likely pulmonary hypertension (>50 mmHg), no overt TR cause (no intrinsic tricuspid disease, LVEF ≥50%, no pacemaker/defibrillator wire across the tricuspid, no other significant valve disease, no disease that may cause TR, no congenital or pericardial heart disease); and no previous valve surgery. Patients with isolated TR and other aetiologies were compared.

Results

2121 patients with at least moderate TR were included. Isolated TR was found in 398 patients (18.8%). Basal characteristics are shown in table 1. Patients with isolated TR did not have a higher prevalence of AF (47.5% vs. 48.6% p=0.362). Isolated TR was less severe (20.5% vs. 32.1% of patients with severe TR; p<0.001) and less symptomatic (NYHA ≥ II in 27.8% of patients vs. 69.3%; p<0.001).

After selecting patients with at least severe TR, patients with isolated TR were also less symptomatic (NYHA≥II in 47.8% of patients vs. 70.7%; p<0.001) and they had better RV function (TAPSE <17 mm in 13.4% vs. 35.6%; p=0.001).

We found that patients with isolated severe TR had a larger tricuspid annulus diameter (25.4±0.8 mm/m2 vs. 24.0±0.3 mm/m2; p=0.047).

Conclusions

In this large prospective study, isolated TR is present in 18.8% of significant TR. Isolated TR was less severe, was associated with less RV dilatation (but with larger tricuspid annulus diameter) and patients had a better functional class compared to other TR aetiologies.

Differeces in NYHA and RV function

Funding Acknowledgement

Type of funding source: None

Outcomes in severe tricuspid regurgitation by CMR: when severe is too severe

Introduction

Tricuspid regurgitation (TR) is related to poor prognosis independently of the etiology. Recently a new scale classification has been proposed to better characterize the grading of more than severe TR. Massive and torrential TR seem to have worse prognosis based on recent echocardiographic studies. There is no information on how that classification would apply when TR is quantified by cardiac magnetic resonance (CMR).

Purpose

To define the cut-off value of massive and torrential TR by CMR and to investigate its potential prognostic implications.

Methods

Consecutive patients in stable clinical status with significant TR evaluated in the Heart Valve Clinic with a contemporaneous echo and CMR were included. TR severity was evaluated by biplane vena contracta and effective regurgitant orifice method, using EPIQ system and by TR regurgitant fraction using a 1.5 Tesla CMR Philips scanner. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure.

Results

A total of 56 patients were included (mean age was 72±9 years, 74% females). According to echocardiography n=43 (76%) were severe TR, n=8 (14%) were massive IT and n=5 (9%) were torrential TR. Patients with massive and torrential TR showed higher RV end-diastolic volume and lower RVEF. A TR regurgitant fraction (TRF) >50% held the best accuracy to define massive / torrential TR. During a median follow up of 2.4 years (IQR: 1.1–3.3 years) 31% of the patients reached the combined endpoint. TR regugitant fraction was predictive of worse prognosis (hazard ratio per 1%TRF=1.085 [1.024–1.150] p=0.003). Patients with a massive and torrential TR showed a significantly higher rate of events (figure). Figure shows on the left (A) spline curves displaying survival free of events for each value of TR regurgitant fraction. y-axis represents the hazard ratio regurgitation fraction (green line) and 95% confidence interval (shadow). On the right (B) Kaplan Meier curves show a significantly higher rate of events in patients with RF>50%.

Conclusions

Our results confirm that patients with massive/torrential TR are populations at higher risk of cardiovascular events. New classification scheme may be included in CMR grading scales. Further research will establish who may benefit the most of intensive therapeutic treatments and intervention on the tricuspid valve.

Funding Acknowledgement

Type of funding source: None

Beyond effective regurgitant orifice in quantitative assessment of tricuspid regurgitation: impact on clinical outcomes

Background

Quantification in tricuspid regurgitation has been poorly investigated. Recommended methods and thresholds are directly translated from mitral regurgitation; however, the anatomy, hemodynamics, and regurgitant orifice geometry are different in TR. Effective regurgitant orifice (ERO) calculation may be incorrect in very severe TR when right atrial and ventricular pressures could get equalized resulting in typically very low TR velocities.

Purpose

Our aim was to compare the prognostic value of different parameters for the evaluation of the tricuspid regurgitation (TR).

Methods

Consecutive patients with significant TR (≥ moderate echocardiographic grade) evaluated in the Heart Valve Clinic were included. TR severity was evaluated by TR radius, TR flow rate, ERO and TR regurgitant volume by PISA method and biplane vena contracta (VC) width using EPIQ system. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure.

Results

A total of 100 patients were included (mean age: 76±10 years, 65% females, 86% functional TR, 84% in NYHA I/II). During a mean follow up of 24±10 months 36% of the patients reached the combined end-point. Patients with events showed more severe TR independently of the parameter applied (table). In univariate analysis, TR radius, TR flow rate, ERO and TR regurgitant volume were predictors of the combined endpoint (p<0.05 for all). Among all parameters, TR flow rate was the strongest and independent predictor of outcomes in multivariate and ROC analysis (HR per 1 ml/seg 1.02 [1.003–1.026], p=0.01). A value of TR flow rate of 109 ml/sec reached the best accuracy to predicted poor outcomes (p<0.01).

Conclusion

Among different parameters to graduate TR severity, TR flow rate was the strongest predictor of outcomes. Since it does not include the TR velocity in the calculation, its incremental benefit may be related to very severe cases of TR. In this scenario, right atrial and ventricular pressures are equalized and TR velocity calculation is not longer possible. New grading schemes for TR may include this parameter in the classification.

Funding Acknowledgement

Type of funding source: None

P726 Cardiac amyloidosis: unmasking the simulator

Introduction

A non-invasive diagnosis of cardiac amyloidosis is a challenge, especially in cases of atypical phenotypic presentation. Differential diagnosis includes hypertrophic cardiomyopathy (HCM), hypertensive cardiomyopathy, and other infiltrative disorders. Multimodality imaging is essential to make a final diagnosis.

Case

We present the case of a 65 years old woman, with a personal history of resistant arterial hypertension and mild hypertensive cardiomyopathy. She was diagnosed 6 years earlier with multiple myeloma, treated with chemotherapy and allogeneic hematopoietic stem cell transplant, presenting with several relapses and in a stable situation at the moment of our first consult. The patient was referred for heart failure in context of acquired community pneumonia one month earlier.

Transthoracic echocardiography showed severe asymmetric left ventricle (LV) hypertrophy (Image A), systolic anterior motion of the mitral valve and diastolic dysfunction suggestive of HCM, not present in the previous examination. Strain imaging of the LV showed a typical amyloid infiltration pattern, with lower longitudinal strain values in the base compared to the apical segments (Image D). Further characterization of the myocardial tissue established the diagnosis along with performing a cardiac magnetic nuclear imaging (MRI). It showed the presence of inferior septum severe LV hypertrophy along with extensive patchy late gadolinium enhancement (LGE) of the lateral wall involving the endocardium (Image C), with normal LV contractility. There was no pleural effusion, but a small pericardial effusion was seen (Image B). With the suspicion of infiltrative heart disease, probably amyloid with an atypical LGE pattern, an oral mucosal biopsy was performed confirming amyloid diagnosis (Images E1,E2). Heart failure treatment was continued, but clinical evolution was poor with the deceasement of the patient 3 years after diagnosis.

Discussion

This case represents an example of the variety of imaging patterns we can see in cardiac amyloidosis. Despite the classical pattern of cardiac amyloidosis, with concentric LV hypertrophy, up to 8% of cases may present with asymmetrical LV hypertrophy, mimicking HCM. LGE extension and pattern can shows this variability as well: global transmural or subendocardial LGE is the most common, but focal patterns (up to 6% of cases) are described. The complexity of the diagnosis in these cases require a clinical and multimodality image approach.

Abstract P726 Figure. Images of the case

P288 Prognostic role of hemoglobin levels in patients with severe tricuspid regurgitation

Background

Patients with severe tricuspid regurgitation (TR) frequently develop heart failure (HF) and their surgical therapeutic options are limited because of very high or prohibitive risk. According to the 2016 ESC guidelines for HF, anaemia and iron deficiency are associated with worse prognosis and intravenous iron therapy should be considered in symptomatic patients with HF reduced ejection fraction (HFrEF) in order to alleviate symptoms, improve exercise capacity and quality of life. The effect of treating iron deficiency in HF preserved ejection fraction (HFpEF) is unknown. The purpose of this study was to analyze the correlation between levels of hemoglobin (Hb) and the prognosis in patients with severe TR and preserve EF.

Methods

Consecutive patients with significant TR (moderate to severe or severe by echocardiography) evaluated in the Heart Valve Clinic between 2015-2018 were included. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure.

Results

A total of 70 patients were included (mean age was 74± 8 years, 71% females). According to aetiology, 94% were functional TR (60% due to left valve disease, 27% due to tricuspid annulus dilatation, 13% others). Mean left ventricular ejection fraction was 56,5% ±6,7%. During a median follow up of 18 months [IQR: 4-28], 35% of the patients reached the combined end-point (n = 16 developed right HF, n = 17 underwent tricuspid valve surgery, and n = 3 died). Patients with events showed lower Hb values (p = 0.04). The level of anaemia was a prognostic factor of the combined endpoint (per gr/dl, HR 0.77 [0-61-0.98], p = 0.036).

Conclusion

Hemoglobin is predictive of poor outcomes in patients with significant TR. According to these preliminary results, iron deficiency could be a therapeutic target in this subgroup of patients with limited therapeutic options.

P906 Are all severe Tricuspid Regurgitation the same?

Introduction

Tricuspid regurgitation (TR) importance is growing in the last years. Its presence is associated with a worse prognosis. A new severity classification has been published, adding massive and torrential to the classical TR classification. However, both clinical profile of the patients as well as right chambers morphologic and functional changes have not been described compared to the severe TR patients.

Methods

Consecutive patients undergoing an echocardiographic study in 9 Spanish hospitals within a three-month period with at least moderate TR were prospectively included. All studies with severe TR were selected for analysis. TR assessment was performed as recommended by the European Association of Cardiovascular Imaging. TR severity grades was performed according to Hanh & Zamorano new published classification. Two cohorts were made: patients with severe TR and patients with massive or torrential TR.

Results

A total of 644 patients with severe or bigger TR were analysed. Severe TR was present in 540 (84%), massive was present in 83 (13%) and torrential in 21 (3%) Baseline characteristics of the study population are shown in table 1.

No differences were found in NYHA class or atrial fibrillation incidence between groups. Pacemaker was more frequent in massive/torrential group (30% vs 19%; 0,014).

Patients with massive/torrential TR presented worst RV remodelling data:

-RV was dilated (RV telediastolic basal diameter >42mm) in 84.2% of patients with massive/torrential TR vs 57% of patients with severe TR (p < 0.001).

-Right atrium was bigger in patients with massive/torrential TR (21 ± 0.8 cm2/m2 vs 17.2 ± 0,3 cm2/m2; p < 0.001)

-Tricuspid annulus diameter was bigger between massive/torrential TR patients (26.7 ± 0.6 cm/m2 vs 23.6 ± 0.3 cm/m2; p > 0.001).

No significant differences in prevalence of RV function (TAPSE < 17 mm) were noted 39% vs 33%, p = 0,273.

Conclusions

In this large multicentre cohort of patients, the presence of massive/torrential TR seems to be associated with a differential RV and RA remodelling, reflecting the greater volume overload seen in these patients. Further studies are needed to define prognosis implication of our findings and its role in clinical decision making.

Table 1 Variable Severe (n = 540) Massive/Torrential (n = 104) Body mass index 26,6 (±0,3) 26.4(±0,6) 0.350 Woman 336 (62%) 69 (66%) 0.438 Atrial firilation 298(55%) 61(59%) 0.514 Age (years) 76,5 (±0,5) 77,5(±1,1) 0.209

39 Overview of tricuspid regurgitation (tr). new classification of tr. when severe tr is too severe?

Introduction

Tricuspid regurgitation (TR) importance is growing in the last years. Its presence is associated with a worse prognosis. A new severity classification has been published, adding massive and torrential to the classical TR classification. However, it is not know how many of the patients classified as severe TR, corresponds to the new Torrential or massive classification that for sure will lead to different treatment strategies. Also few published studies have addressed the aetiologies, mechanisms and severity in large cohorts.

Purpose

To evaluate the burden of TR in a large cohort of patients referred for an echocardiography.

Methods

Prospective study where consecutive patients undergoing an echocardiographic study in 10 Spanish hospitals within a three-month period were included. All studies with at least moderate TR were selected for analysis. The evaluation was conduced according to the usual practice of the laboratory. TR assessment was performed as recommended by the European Association of Cardiovascular Imaging. TR was quantified according to Hanh & Zamorano new published classification.

Results

A total of 35088 consecutive echocardiographic studies were performed in the participant hospitals during the recruitment period. TR of at least moderate degree was detected in 2124 studies (6,05%). Mean age was 77,1 years and 62.8% were women.

Mitral or aortic valvulopthy was the most common cause, present in almost half of cases (48.4%). The second cause of TR was idiopathic with 22.2% of cases. Primary TR was found in 7.2% of patients, the most frequent aetiology in these group was cardiac implantable devices with 4.2% of total of TR. Aetiology and severity according to the new classification can be seen in the figures

Atrial fibrillation was present in 47.6% of cases. 56.4% of patients had symptoms at the time of the study (NYHA≥2 at the time of study).

Right ventricle (RV) was dilated (telediastolic basal diameter >42mm) in 39.4% of patients). RV function was impared (TAPSE <17mm) in 30.6% of patients.

Conclusions

In these larger multicentre study, significant TR may is present in up to 6% of the echocardiographic studies and is often symptomatic[m1] . 4,91% of patients had a massive or torrential grade. Most TR are secondary to mitral or aortic valvulopathy. Idiopathic TR has taken the second place.

Abstract 39 Figure. Severity and aetiology of TR

P727 Unexpected ventricular aneurysm: further ischemic aetiology

Introduction

Ventricular aneurysm is an infrequent complication of myocardial infarction. In absence of an ischemic event, alternative aetiologies include: thoracic trauma, hypertrophic cardiomyopathy, myocarditis, Chagas disease, cardiac sarcoidosis or arrythmogenic cardiomyopathy. In the absence of any of the previous, congenital aneurysm diagnosis is made.

Case

We present the case of 57-year-old man referred to cardiology department because a new onset of atrial fibrillation with left bundle branch block. Past medical history included high blood pressure and dyslipidaemia without any history or smoking, alcohol consumption or any other toxic abuse. No chest pain, shortness of breath or other significant symptoms were reported. Physical examination was unremarkable except for an arrhythmic pulse at 85-90 bpm.

Echocardiogram showed moderate dilated left ventricle with mild-moderate LV dysfunction (EF 40% ) with a septal aneurysm of 2.4x1cm (Picture A). A coronary CT was performed that ruled out coronary heart disease and confirmed the presence of the septal aneurysm (Picture B). To better characterize this image, a cardiac magnetic resonance (CMR) was performed. Moderate dilated LV with significant dysfunction (EF 31%) was reported. A septal aneurysm of 13 x 22 x 33 mm composed of a 2.8 m thin wall of true myocardial tissue was documented (picture C and D-late gadolinium enhance). No myocardial delayed enhancement was detected in any area of the LV. Moreover, no signs of myocardial non compaction, arrythmogenic cardiomyopathy, hypertrophic cardiomyopathy or myocarditis were seen. Chagas serology as well as sarcoidosis diagnosis work up were negative. Patient denied any thoracic traumatism. Congenital aneurysm diagnosis was finally established.

Electrical cardioversion was performed after 1 month of correct oral anticoagulation and heart failure treatment was started. Case was presented in the Heart Team session and a conservative management was decided based on asymptomatic status and absence of ventricular arrhythmias. After 3 years of clinical follow up, the patients is in good status, asymptomatic and in sinus rhythm. Discussion: Congenital ventricular aneurysm is a rare cardiac malformation that arises during the fourth embryonic week. Most frequently, left ventricular aneurysms are found in the apex and the perivalvular area, being the septal location an atypical one. Most patients are asymptomatic but when symptoms occur, they are mostly related to the presence of ventricular arrhythmias. Aneurysm rupture incidence is variable, ranging from 3.7% to 12 % according to the different series. For this reason, surgery is recommended in symptomatic patients. However, management of asymptomatic patients is not clear since prognosis studies are lacking.

Abstract P727 Figure. A.Echo B.-CT C.-CMR. D.-CMR gadolinium

P3370Prevalence of right ventricular dysfunction according to different parameters: basal and one year after transcatheter aortic valve implantation

Background

Right ventricle (RV) is not often specifically studied in patients with severe aortic stenosis (AS). It's difficult to find the correct tool to assess RV function with echocardiographic parameters, and the percentage of patients with dysfunction may vary depending on the parameter that we use.

The aim of the study was to evaluate the prevalence of RV dysfunction basal and one year after transcatheter aortic valve implantation (TAVI), according to different parameters.

Methods

Consecutive patients with severe AS undergoing TAVI from January 2016 to July 2017 were included. RV anatomical and functional parameters were analyzed according to ESC and ASE guidelines. RV dysfunction was assessed using tricuspid annular plane systolic excursion (TAPSE) <17 mm, fractional area change <35%, systolic movement of the RV lateral wall by tissue Doppler imaging (RV-S'TDI) <9.5 cm/s, global longitudinal (RV-GLS) and free wall strain (RV-FWS) using as cutting point [20]. Pre procedure echo, immediate post procedure and 1 year echo were analyzed. Statistical analysis was performed using SSPS version 22.

Results

The final study population consisted of 78 patients (115 patients were included, 37 were excluded due to suboptimal acoustic window for RV anatomical and functional evaluation), mean age 83.73±6.31 year-old, 38.2% females. We analyzed the percentages of RV dysfunction according to the different parameters evaluated before and in the control one year after. They are shown in Figure 1.

Prevalence of RV dysfunction

Conclusions

The presence of RV dysfunction in patients with severe AS is higher than expected Our data suggest that RV function improve one year after TAVI, in terms of a reduction in the number of patients with dysfunction. The assessment of RV function is difficult, and there is no agreement on what tools are more accurate and useful. RV strain seems to be the most sensible parameter to assess RV function in patients with AS undergoing TAVI. Impact of these measurements in patients management needs further evaluation.

2139Left atrial dysfunction assessed by strain correlates with symptoms and severity of aortic stenosis

Background

Aortic stenosis (AS) results in high pressure afterload causing detrimental effect especially on the left chambers. Structural and functional changes of the left ventricle (LV) usually corresponds to concomitant remodelling of the left atrium (LA). However, how this pressure afterload specifically affects LA function and whether the study of LA function could help in stratifying patients with different degree of AS it is not known.

Purpose

We aim to evaluate the differences in LA and LV function according different degree of AS by standard and speckle tracking echocardiographic.

Methods

From January 2016 to May 2018 we recruited 135 patients referring to our echo-lab with diagnosis of AS (mean age 79.5±4.4; 60/55% female). We divided this population according to AS severity in patients with moderate AS, severe asymptomatic and severe symptomatic AS and matched with 35 control group with no aortic stenosis (n=45, mean age: 77.6±4.5). All patients underwent standard and 2-dimensional speckle tracking echocardiography computing global longitudinal strain (GLS) of LV and peak atrial strain of LA (PALS).

Results

In all patients PALS was a good predictor of E/e' ratio after correction for LV EF and age (p<0.001, β: −0.48). LVEF and GLS progressively decreased together with worsening of AS degree, as well as parameters of geometry and function of LA (Table1). By excluding patients with LV dysfunction the reduction gradient of parameters of LA geometry and function was still present. However, when severe symptomatic with asymptomatic severe AS are compared, no difference in E/e' ratio was found while both GLS and PALS were significantly reduced (both p<0.0001).

Variables Overall population (180) Control (45) Moderate AS (45) Severe asympt AS (45) Severe sympt. AS (45) p LVEF 65.0±11.1 67.7±5.6 69.4±8.5 66.1±10.7 59.5±13.5 0.0001 GLS −20.4±4.1 −23.1±2.4 −21.5±2.9 −21.4±3.2 −17.1±4.3 0.0001 LA vol index 41.6±21.5 28.2±10.4 40.1±19.7 39.8±16.7 52.3±24.9 0.0001 LA strain 23.6±10.9 30.8±10.3 27.8±9.2 24.4±9.7 15.2±7.1 0.0001 LA reservoir 46.4±15.9 51.9±11.5 53.0±15.0 48.3±14.1 37.2±16.1 0.0001 Ee' ratio 14.8±7.0 9.6±2.7 13.7±6.3 15.4±6.2 19.3±7.2 0.0001

Conclusions

LA function seems to progressively decrease according to the degree of AS, independently from LV function. Significant difference was found between parameters of LA remodelling and dysfunction between symptomatic and asymptomatic AS patients. The assessment of LA function by strain may help stratify the patients with AS, identifying those who need intensive medical/surgical treatment.