A novel staging system of cardiac damage in aortic stenosis based on multi-chamber myocardial deformation

Aims: This study evaluates whether multi-chamber myocardial deformation analysis using speckle tracking echocardiography (STE) can enhance validated current staging systems and improve risk stratification for patients with moderate-to-severe aortic stenosis (AS). Methods and results: We reanalysed 2D, Doppler, and STE data obtained from two cohorts: derivation (654 patients, median age: 82 years; 51% men) and validation (237 patients, median age: 77 years; 55% men) with at least moderate AS (aortic valve area < 1.5 cm2). The receiver operator characteristic curve analysis identified optimal cut-off values linked to outcomes: 15% for left ventricular global longitudinal strain (LVGLS), 13% for peak atrial longitudinal strain (PALS), and 19% for right ventricular free-wall strain (RVFWS). Patients have been divided into five stages: Stage 0, no left-side damage (LVGLS ≥ 15% and PALS ≥ 13%); Stage 1, partial left-side damage (LVGLS < 15% or PALS < 13%); Stage 2, definite left-side damage (LVGLS < 15% and PALS < 13%); Stage 3, no right-side damage (RVFWS ≥ 19%); and Stage 4, right-side damage (RVFWS < 19%). In a multivariable Cox regression analysis, the new staging scheme remained independently associated with an increased risk of all-cause death [adjusted-hazard ratio: 1.28; 95% confidence interval (CI): 1.10-1.48; P = 0.001]. This new staging classification exhibited higher predictive power [area under the curve (AUC) 0.67; 95% CI 0.62-0.73] than those proposed by Généreux et al. (Staging classification of aortic stenosis based on the extent of cardiac damage. Eur Heart J 2017;38:3351-8.) (AUC 0.62; 95% CI 0.56-0.67; P = 0.002) and Tastet et al. (Staging cardiac damage in patients with asymptomatic aortic valve stenosis. J Am Coll Cardiol 2019;74:550-63.) (AUC 0.64; 95% CI 0.58-0.70; P = 0.041) for 2-year all-cause death, with similar findings in the validation cohort. Conclusion: Our staging system for detecting cardiac damage, incorporating multi-chamber myocardial deformation, exhibits a stronger association with outcomes than previously validated systems.