CLINICAL INVESTIGATIONS VALVULAR HEART DISEASE Recovery of Left Ventricular Mechanics after Transcatheter Aortic Valve Implantation: Effects of Baseline Ventricular Function and Postprocedural Aortic Regurgitation Fr ed eric Poulin, MD, MSc, Shemy Carasso, MD, Eric M. Horlick, MDCM, Harry Rakowski, MD, Ki-Dong Lim, MD, Heather Finn, MBBS, Christopher M. Feindel, MD, Matthias Greutmann, MD, Mark D. Osten, MD, Robert J. Cusimano, MD, and Anna Woo, MD, SM, Toronto, Ontario, Canada Background: Impaired left ventricular (LV) myocardial deformation is associated with adverse outcome in patients with severe aortic stenosis (AS). The aim of this retrospective study was to assess the impact of transcatheter aortic valve implantation (TAVI) on the recovery of myocardial mechanics and the influence of postprocedural aortic regurgitation (AR). Methods: Speckle-tracking echocardiography was used to assess multidirectional myocardial deformation (longitudinal and circumferential strain) and rotational mechanics (apical rotation and twist) before and at midterm follow-up after TAVI. Predictors of myocardial recovery, defined as a $20% relative increase in the magnitude of global longitudinal strain compared with baseline, were examined. Results: Sixty-four patients (median age, 83 years; interquartile range, 77–86 years) with severe AS and high surgical risk (mean European System for Cardiac Operative Risk Evaluation score, 20 6 13%) were evaluated. Overall, LV longitudinal deformation was impaired at baseline compared with controls. At 5 6 3 months after TAVI, LV longitudinal deformation had significantly improved only in the group of patients with baseline LV ejection fractions (LVEF) # 55%: global longitudinal strain from 9.7 6 3.7% to 11.8 6 3.2% (P = .05), lon- gitudinal strain rate from 0.44 6 0.14 sec 1 to 0.57 6 0.16 sec 1 (P = .001), and early diastolic strain rate from 0.38 6 0.17 sec 1 to 0.49 6 0.18 sec 1 (P = .01). In patients with normal LVEFs, LV twist was supraphy- siologic at baseline and normalized after TAVI (from 16.1 6 6.9  to 11.9 6 6.2  , P = .004). In patients with base- line LVEFs # 55%, circumferential deformation was impaired before TAVI and improved after TAVI. Baseline LVEF (odds ratio, 0.56 per 10% increment; P = .02) and global longitudinal strain (odds ratio, 0.65 per absolute 1% increment; P < .001) were significant predictors of myocardial recovery. LV mass, volumes, and longitu- dinal strain failed to favorably remodel in patients with post-TAVI important AR (defined as new mild post-TAVI AR or moderate or severe post-TAVI AR [either preexisting or new AR]). Conclusions: TAVI restores LV function toward more physiologic myocardial mechanics in both normal- and depressed-LVEF groups. Patients with lower systolic function derive the most benefit in terms of longitudinal reverse remodeling. Postprocedural AR adversely affects LV structural and functional remodeling. (J Am Soc Echocardiogr 2014;27:1133-42.) Keywords: Aortic stenosis, Transcatheter aortic valve implantation, Speckle-tracking echocardiography, Myocardial mechanics, Strain, Paravalvular aortic regurgitation Aortic stenosis (AS) causes chronic pressure overload on the left ventricle, leading to concentric hypertrophy, subendocardial ischemia, myocardial fibrosis, impaired diastolic filling, and potentially systolic dysfunction. 1 Transcatheter aortic valve implantation (TAVI) is a novel therapy for patients with severe AS at high risk for open-heart surgery. 2 Patients who have undergone TAVI are older and have more serious comorbidities than patients who have been referred for con- ventional surgical aortic valve replacement (AVR). 3 One potential disadvantage of TAVI is an increased incidence of postprocedural aortic regurgitation (AR), which is an independent predictor of short- and long-term mortality and which may have a negative impact on LV myocardial recovery. 4,5 Speckle-tracking echocardiography (STE) allows the quantitative angle-independent assessment of myocardial mechanics in different axes and rotations. STE provides strain and strain rate (SR) From the Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada Reprint requests: Fr ed eric Poulin, MD, MSc, Toronto General Hospital, 200 Elizabeth Street, 4N-506, Toronto, ON M5G 2C4, Canada (E-mail: frederic.poulin@uhn.ca). 0894-7317/$36.00 Copyright 2014 by the American Society of Echocardiography. http://dx.doi.org/10.1016/j.echo.2014.07.001 1133