Prognostic significance and clinical utility of left atrial reservoir strain in transcatheter aortic valve replacement.

Patients with diastolic dysfunction (DD) experience worse outcomes after transcatheter aortic valve replacement (TAVR). We investigated the prognostic value and clinical utility of left atrial reservoir strain (LARS) in patients undergoing TAVR for aortic stenosis (AS). All consecutive patients undergoing TAVR between 01/2018 and 12/2018 were included if discharge echocardiography and follow-up were available. LARS was derived from 2-D-speckle-tracking. Patients were grouped into 3 tertiles according to LARS. DD was analyzed using the ASE/EACVI-algorithm. The primary outcome was a composite of all-cause death and readmission for worsening heart failure 12 months after TAVR. Overall, 606 patients were available (age 80 years, interquartile range [IQR] 77-84), including 53% women. Median LARS was 13.0% (IQR 8.4-18.3). Patients were classified by LARS tertiles (mildly-impaired 21.4% [IQR 18.3-24.5], moderately-impaired 13.0% [IQR 11.3-14.6], severely-impaired 7.1% [IQR 5.4-8.4], p<0.0001). The primary outcome occurred more often in patients with impaired LARS (mildly-impaired 7.4%, moderately-impaired 13.4%, severely-impaired 25.7%, p<0.0001). On adjusted multivariable Cox-regression analysis, LARS-tertiles (HR 0.62, 95% CI 0.44-0.86, p=0.005) and higher degree of tricuspid regurgitation (HR 1.82, 95% CI 1.23-2.98, p=0.003) were the only significant predictors of the primary endpoint. Importantly, DD was unavailable in 56% of patients, but LARS-assessment allowed for reliable prognostication regarding the primary endpoint in subgroups without DD assessment (HR 0.64, 95% CI 0.47-0.87, p=0.003). Impaired LARS is independently associated with worse outcomes in patients undergoing TAVR. LARS allows for risk-stratification at discharge even in patients where DD cannot be assessed by conventional echocardiographic means.

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