Introduction: The changes and the prognostic implications of left atrial (LA) volumes (LAV), LA function, and vascular load in patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) are less known. Methods: We enrolled 150 symptomatic patients (mean age 82 ± 8 years, 58% female, and pre-TAVI aortic valve area 0.40 ± 0.19 cm/m2) with severe AS who underwent 2D transthoracic echocardiography and 2D speckle tracking echocardiography at average 21 ± 35 days before and 171 ± 217 days after TAVI. The end point was a composite of new onset of atrial fibrillation, hospitalization for heart failure and all-cause death (major adverse cardiac events [MACE]). Results: After TAVI, indexed maximal LA volume and minimum volume of the LA decreased by 2.1 ± 10 mL/m2 and 1.6 ± 7 mL/m2 (p = 0.032 and p = 0.011, respectively), LA function index increased by 6.8 ± 11 units (p < 0.001), and LA stiffness decreased by 0.38 ± 2.0 (p = 0.05). No other changes in the LA phasic volumes, emptying fractions, and vascular load were noted. Post-TAVI, both left atrial and ventricular global peak longitudinal strain improved by about 6% (p = 0.01 and 0.02, respectively). MACE was reached by 37 (25%) patients after a median follow-up period of 172 days (interquartile range, 20–727). In multivariable models, MACE was associated with both pre- and post-TAVI LA global peak longitudinal strain (hazard ratio [HR] 0.75, CI 0.59–0.97; and HR 0.77, CI 0.60–1.00, per 5 percentage point units, respectively), pre-TAVI LV global endocardial longitudinal strain (HR 1.37, CI 1.02–1.83 per 5 percentage point units), and with most of the LA phasic volumes. Conclusion: Within 6 months after TAVI, there is reverse LA remodeling and an improvement in LA reservoir function. Pre- and post-TAVI indices of LA function and volume remain independently associated with MACE. Larger studies enrolling a greater diversity of patients may provide sufficient evidence for the utilization of these imaging biomarkers in clinical practice.

232BARASCH E et al. Circulation JournalOfficial Journal of the Japanese Circulation Society http://www. j-circ.or.jp he prevalence of aortic valve (AV) structural changes and calcification increases with age such that approximately 30% of individuals over the age of 65 years have AV sclerosis while 4% have overt aortic stenosis (AS). 1 In apparently healthy subjects 75-86 years old, the prevalence of moderate to severe AS increases from 2.5% at 75-76 years to 8.1% at 85-86 years. 2 The natural history of AS is well established: after the onset of angina pectoris, syncope or heart failure, annual mortality approaches 25% with an average survival of 2-3 years. 3 Because there is no effective medical therapy, AV replacement (AVR), whether performed by surgical or percutaneous approach, represents the only definitive therapy.Among patients who otherwise meet criteria for AVR, surgery is not performed in between 33% and 61%. 4,5 Because the mortality of these patients is approximately twice that of similar patients undergoing AVR, 6 and the main reasons for surgical ineligibility are comorbidities that significantly increase operative risk, 7 refining risk stratification of these patients is important. Objective reassessment of such patients may indicate appropriateness of surgery in up to one-quarter of them, 8 while transcatheter aortic valve implantation (TAVI) has become increasingly available as a potential alternative to surgery. 9 A number of recent studies have described clinical and echocardiographic predictors of death and major cardiac adverse events in patients with severe AS but most have examined the post-surgical 10 or post-TAVI outcome. 11 Prior studies have enrolled patients with severe AS regardless of left ventricular ejection fraction (LVEF). 12,13 In several, LVEF was strongly associated with outcome in both unoperated and operated patients with AS. 4,5, 14 We sought to identify echocardiographic, clinical and laboratory variables associated with all-cause mortality in medically treated patients with severe isolated AS and normal LVEF.

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Background: Aortic valve weight (AVW), a flow independent measure of aortic stenosis (AS) severity, is reported to have heterogeneous associations with the echocardiographic variables used for AS evaluation. Controversy exists regarding its impact on survival after aortic valve replacement (AVR). Objective: We sought to determine the association between AVW with echocardiographic measures of AS severity and all-cause mortality after surgical AVR. Methods: One thousand and forty-sixconsecutive patients underwent surgical AVR for AS, the excised valves were weighed, and an echocardiogram was done before surgery. Results: Males had heavier valves than females, for both absolute and body surface are (BSA)-indexed values (2.78 ± 1.23 vs. 2.08 ± 0.68 g, p < 0.001; and 1.38 ± 0.61 vs. 1.19 ± 0.41 g/m2, p < 0.001, respectively). In a restricted cohort of 634 patients with isolated severe AS and normal ejection fraction, the correlations of AVW with echocardiographic variables of AS were modest, the strongest being with the dimensionless index (r = –0.27 and –0.26 for male and female, both p < 0.01). Stratified by stroke volume index and mean gradient (MG), no associations were found in the low-gradient groups (i.e., MG <40 mmHg). At a median follow-up of 3.5 years, there were only 244 deaths in the entire cohort. Mortality was not related to AVW, except in females who displayed an inverse relationship (HR = 0.67; 95% CI 0.47–0.95) only when it was analyzed as a continuous variable. Conclusions: The weak correlation between AVW with the echocardiographic indices of AS may reflect its complex pathophysiology, heterogeneous hemodynamics, and possible pitfalls in the current echocardiographic methods used in clinical practice. The prognostic value of AVW after AVR warrants further evaluation.