Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Investigaciones Médicas, Cardiodiagnostic Background.  Regional apical longitudinal strain (RALS) allows to corroborate the diagnosis of regional wall motion abnormalities (RWMA) during dipyridamole stress echocardiography (DSE) on a quantitative basis but data on the prognostic value are missing. Objectives.  The to evaluate the physiologic correlates and prognostic value of RALS vs. RWMA during DSE. Methods.  In a single center, observational design we initially evaluated 150 patients (pts), mean age 68.3 ± 9.6 years, 50.7% men referred for DSE.  RALS was defined as the average of the four apical segments from the 3 apical views.  Any increase in the percentage of deformation was considered normal. Coronary flow velocity reserve (CFVR) was also assessed in mid-distal left anterior descending (LAD) coronary artery by pulsed-wave Doppler. Pts were divided into two groups (G). G1: patients with normal RALS, and G2: patients with abnormal RALS.  Major cardiovascular event was considered to be: cardiovascular death, acute myocardial infraction (AMI), stroke or needs for revascularization after 3 months All patients were followed-up. Results. RALS success rate was 94.6% (142 pts), since 8 pts were excluded for inadequeate window. Eighty-seven patients (61.3%) were included in G1 and 55 (38.7%) pts in G2. The mean follow-up was 36 ± 0.93 months. There were no differences in the resting RALS between the G1 and G2 (-22.3% ± 3.3 vs -21.25% ± 4.9, p = NS), but significant differences in the peak dipyridamole effect (-26.3% ± 4.2 vs -18.8% ± 4.1, p < 0.001). Pts G1  showed less RWMA  than pts G2 (G1 3.4% vs  G2 90 %), p < 0.001) and higher CFVR (G1= 2.6 ± 0.5 vs G2 = 1.6 ± 0.4, p < 0.001). Adequeate CFVR showed high concordance with the increase in RALS evaluated  by Kappa Index 0.95, p 0.001 (Pts G1= 98.9% vs pts G2= 96.4%).  In the long-term follow up, 24 pts experienced events: 3 deaths, 3 non-fatal myocardial infarctions, 2 stroke and 16 late revascularizations. Pts with normal RALS had a better event-free survival (G1= 90.8% vs G2 = 70.9%, log Rank p < 0.007, HR: 2.92; 95% CI: 1.27-6.68, p 0.011) (figure 1). In the multivariate analysis of logistic regression, adjusted for age, the RALS was an independent predictor of event. In G2 no significant differences were detected in event free survival in pts with and without visual dyssynergies during DSE (73.7 vs 67.7, respectively (p = ns) Conclusions. A mismatch between RALS and visually assessed RWMA occurs in a significant proportion of patients, and RALS is better correlated to physiologic (CFVR) and prognostic standards. Abnormal RALS during DSE predicted worse outcome, regardless of the RWMA.  Quantitative stress echocardiography is possible feasible and useful during DSE. Abstract Figure. RALS in DSE and Event Free Survival

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Investigaciones Médicas. Cardiodiagnóstico. Buenos Aires Introduction. Left ventricle Global Longitudinal Strain(GLS) at rest has shown prognostic value in patients(pts) with severe aortic stenosis(SAS). Contractile reserve(CR) during exercise stress echo(ESE) estimated by GLS(CR-GLS) could better stratify the asymptomatic patients who could benefit from early intervention.  Objective. To establish the long-term prognostic value of CR-GLS in pts with asymptomatic SAS during ESE. Secondly, to compare if the CR evaluated by ejection fraction(CR-EF) presented similar results to those of CR-GLS.  Methodology. In a single center, prospective study carried out between May 2013 to Oct 2019, we enrolled 101 pts(69 ± 12 years,54 men) with asymptomatic SAS(aortic valve area < 0,6cm2/m2) and preserved EF(>55%). GLS value was considered as the average of the 16 segments, obtained from the apical views of 3, 4 and 2 chambers at rest and peak ESE. CR was considered present with stress-rest increase of >5points with EF and >2 absolute points by GLS. The pts were divided into 2 groups(G): G1:Pts with presence of CR-GLS and G2:Pts with absence of CR-GLS. Major cardiovascular event was considered to be: need for valve replacement due to the presence of symptoms, death, acute myocardial infarction and stroke. All patients were followed-up.  Results. Of the 101 pts analyzed, 56pts(55.4%) were included in G1(CR-GLS) and 45pts(44.6%) in G2(no CR-GLS). The G2 patients were older(G2 72.2 ± 8.5 vs G1 66.5 ± 14.1) with lower METS(G1 5.6 ± 2 vs G2 4.2 ± 1.1,p 0.004), a higher percentage of flat blood pressure response(G1 19.6% vs. G2 37.8%,p 0.036), lower peak EF(G1 71.5%±5.8 vs G2 66.8 ± 7.9,p0.001),peak GLS(G1 -22.2%±2.8 vs G2 -18.45%±2.4 p 0.001) and lower ΔGLSstress-rest(G1 GLS 3.07 ± 0.85 vs G2 0.08 ± 1.9 p 0.003). The same behaviour with the EF response(G1 7.32 ± 2.9 vs G2 4.7 ± 5.3,p 0.024). The average follow-up was 46.6 ± 3.4 months, and events occurred in 45 patients: 12 all-cause deaths(9 cardiac), 31 valve replacement, 1 myocardial infarctions, 1 strokes. G2 pts had more events compared to G1 pts (G2 = 26 events 57.8% vs G1 = 19 events 42.2%,p < 0.01)(figure 1). The CR-EF did not separate patients with and without events. At Cox analysis, CR-GLS was the only predictor variable of major events(HR:1.97, 95% CI 1.09-3.58)p < 0.025). Conclusions In patients with asymptomatic SAS, the absence of CR-GLS during ESE identifies a group of patients with a worse prognosis and the need for aotic valve intervention. CR-GLS proved to be superior tan CR-EF. Baselin characteristic between groups Abstract Figure. Left ventricle RC-GLS and survival

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Investigaciones Médicas, Cardiodiagnostic Introduction. The behavior of the ejection fraction (EF) during exercise stress echocardiography (ESE) is used to measure the left ventricular (LV) contractile reserve (CR). Ventricular Elastance or Force defined as the ratio between systolic blood pressure (SBP) and LV end-systolic volume (ESV) could be better as it is less dependent of heart rate, preload, and afterload conditions. Objective. To establish the relative prognostic value of EF-based and novel Force-based LVCR in patients (pts) without ischemia during ESE. Materials and methods. In a retrospective analysis of prospectively enrolled pts, we enrolled  904 pts, (61.92 ± 12.59 years, 509 men, 56.3%) with negative ESE for RWMA. LV volumes were measured with biplane Simpson’s rule. LVCR was assessed based on EF ≥5 points increase at peak over rest and based on Force peak/rest ratio > 2. The average follow-up was 17.7 ± 5.44 months. Major cardiovascular event was defined as: death, acute myocardial infarction, cerebrovascular accident and/or need for hospitalization due to cardiovascular causes. Results. LVCR by EF was present in 536 (59.3%) and absent in 368 (40.7%) pts. LVCR by Force was present in 200 pts (22.1%) and absent in 704 pts (77.9%) pts. The overall concordance between LVCR assessed by EF and Force was 538 pts (89.6%) with presence of CR by EF and not by Force being the most frequent source of discrepant result in 336 pts.  In the long-term follow up, 52 pts experienced events: 0 all-cause death, 3 acute myocardial infarctions, 5 cerebrovascular accidents and 44 for hospitalization due to cardiovascular causes. Lack of LVCR based on EF identified patients at higher risk (see Figure) but Force-based LVCR allowed to further separate  patients with EF-based LVCR  (n = 536) into a lower risk with (n = 200, event rate 2%) and higher risk subgroup without Force-based LVCR  (n= 336, event rate 5.3 %, p<.01 vs subgroup with Force-based LVCR)  Cox Regression model identified Force-based LVCR  was the only predictor of events (HR: 3.22, 95% CI 1.83-5.6, p < 0.001). Conclusions. In patients with negative SE for RWMA, the evaluation of LVCR based on EF allows a better stratification of outcome, which is further refined by addition of Force-based LVCR, especially useful in the subset with LVCR by EF not confirmed by Force. Force-based LVCR allowed to identify a subgroup of worse long-term prognosis outperforming EF-based LVCR. Abstract Figure. LVCR by EF and Event Free Survival