Aortic valve replacement (AVR) is recommended for patients having severe aortic stenosis (AS) associated with symptoms and/or left ventricular systolic dysfunction defined as left ventricular ejection fraction (LVEF) of less than 50%. Left ventricular dysfunction may, however, develop insidiously in the asymptomatic patient with severe AS and may eventually become irreversible. Accordingly, some recent studies support the realisation of elective surgery in asymptomatic patients with severe AS to improve their long-term survival.1 On the other hand, the risk of operative death associated with elective AVR may outweigh the low risk of sudden death that has been reported in asymptomatic patients. The challenge for the clinician is thus to detect left ventricular contractile dysfunction at an early or subclinical stage so that closer follow-up can be instituted or surgical correction performed to prevent the development of irreversible left ventricular dysfunction and adverse outcomes.

In this issue of Heart, Cramariuc et al2 report the results of an elegant study in which they examined the relationship between myocardial deformation assessed by speckle tracking imaging and left ventricular geometry in patients with AS (see page 106). The main findings of the study are: (1) left ventricular longitudinal myocardial strain is reduced in patients with left ventricular concentric hypertrophy; (2) the extent of longitudinal strain impairment is related to larger left ventricular mass index, higher relative wall thickness ratio (ie, higher degree of concentric remodelling) and more severe stenosis severity.

Thirty years ago in 1979, Dumesnil and colleagues3 were the first to report that patients with AS often have selective decreases in left ventricular …