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Right ventricular longitudinal strain for risk stratification in low-flow, low-gradient aortic stenosis with low ejection fraction
  1. Abdellaziz Dahou1,
  2. Marie-Annick Clavel1,
  3. Romain Capoulade1,
  4. Philipp Emanuel Bartko2,
  5. Julien Magne3,4,
  6. Gerald Mundigler2,
  7. Jutta Bergler-Klein2,
  8. Ian Burwash5,
  9. Julia Mascherbauer2,
  10. Henrique B Ribeiro1,
  11. Kim O'Connor1,
  12. Helmut Baumgartner6,
  13. Mario Sénéchal1,
  14. Jean G Dumesnil1,
  15. Raphael Rosenhek2,
  16. Patrick Mathieu1,
  17. Eric Larose1,
  18. Josep Rodés-Cabau1,
  19. Philippe Pibarot1
  1. 1Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
  2. 2Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
  3. 3Service Cardiologie, CHU Limoges, Hôpital Dupuytren, Limoges, France
  4. 4Faculté de médecine de Limoges, INSERM 1094, Limoges, France
  5. 5University of Ottawa Heart Institute, Ottawa, Ontario, Canada
  6. 6Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
  1. Correspondence to Dr Philippe Pibarot, Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5; philippe.pibarot{at}


Background Left ventricular global longitudinal strain (LVLS) is a powerful predictor of outcome in patients with low-flow, low-gradient aortic stenosis (LF-LG AS) and low LV ejection fraction (LVEF). However, the impact of right ventricular (RV) function on the outcome of these patients remains unknown.

Objectives The aim of this study was to examine the impact of RV function as evaluated by RV free wall longitudinal strain (RVLS) on mortality in patients with LF-LG AS and low LVEF.

Methods 211 patients with LF-LG AS (mean gradient <40 mm Hg and indexed aortic valve area (AVA) ≤0.6 cm2/m2) and low LVEF (≤40%)) were prospectively recruited in the True or Pseudo-severe Aortic Stenosis study. AS severity was assessed using the projected AVA (AVAproj) at normal flow rate. Among the 211 patients, 128 had RVLS measurement available at rest and were included in this analysis. RVLS measurement at dobutamine stress echocardiography (DSE) was available in 58 of the 128 patients.

Results Two-year survival was lower in patients with RVLS<|13|% (53%±9%) compared with those with RVLS>|13|% (69%±5%) (p=0.04). In multivariable Cox analysis stratified for the type of treatment (aortic valve replacement vs conservative) and adjusted for age, AS severity, previous myocardial infarction and LVLS, rest RVLS<|13|% (HR=2.70; 95% CI 1.19 to 6.11; p=0.018) was independently associated with all-cause mortality. RVLS had incremental prognostic value over baseline risk factors and LVLS (χ2=20.13 vs 13.56; p=0.01). Reduced stress RVLS was also associated with increased risk of mortality (stress RVLS<|14|%: HR=2.98; 95% CI 1.30 to 6.52; p=0.01). In multivariable Cox analysis, stress RVLS<|14|% remained independently associated with mortality (HR=2.94; 95% CI 1.23 to 7.02; p=0.015). After further adjustment for rest RVLS, stress RVLS<|14|% remained independently associated with mortality (HR=3.29; 95% CI 1.17 to 9.25; p=0.024), whereas rest RVLS was not (p>0.05).

Conclusions In this series of patients with LF-LG AS and low LVEF, reduced RVLS was independently associated with increased risk of mortality. Furthermore, stress RVLS provided incremental prognostic value beyond that obtained from rest RVLS. Thus, RVLS measurement at rest and at DSE may be helpful to enhance risk stratification in this high-risk population.

Trial registration number NCT01835028; Results.

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