Left Atrial Dysfunction as an Independent Correlate of Heart Failure Symptoms in Patients With Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction Anca D. Mateescu, MD, Andreea C alin, MD, PhD, Carmen C. Beladan, MD, PhD, Monica Ros ¸ca, MD, PhD, Roxana Enache, MD, PhD, Cristian B aicus ¸, MD, PhD, Simona Botezatu, MD, Carmen Ginghin a, MD, PhD, and Bogdan A. Popescu, MD, PhD, Bucharest, Romania Background: Data regarding the contribution of left atrial (LA) dysfunction to the occurrence of heart failure in patients with severe aortic stenosis (AS) are scarce. The aim of this study was to assess the relationship be- tween LA deformation and symptomatic status in this clinical setting. Methods: A total of 361 consecutive patients with severe AS (aortic valve area [AVA] index # 0.6 cm 2 /m 2 ) referred to the echocardiography laboratory were prospectively screened. Two hundred forty-eight patients with preserved left ventricular (LV) ejection fraction ($50%), in sinus rhythm, and with no more than mild aortic or mitral regurgitation (202 symptomatic and 46 asymptomatic) were enrolled. Asymptomatic status was confirmed by exercise echocardiography or electrocardiography, as clinically indicated. All patients under- went comprehensive echocardiography, including speckle-tracking analysis of LV and LA deformation. Results: No significant differences were found between the two groups regarding age and cardiovascular risk factors. LV ejection fraction and geometric parameters were similar between groups despite higher indexed AVA in asymptomatic patients. In symptomatic patients, brain natriuretic peptide values, average E/e 0 ratio, and LA size were higher, whereas LV global longitudinal strain and peak LA longitudinal strain and strain rate parameters were lower compared with asymptomatic patients. AVA and peak systolic LA longitudinal strain rate were the only independent correlates of heart failure symptoms (P = .04 and P = .01, respectively). Conclusions: LA systolic strain rate, in addition to AVA, emerged as an independent correlate of the presence of heart failure in patients with severe AS and preserved LV ejection fraction. The echocardiographic evalua- tion of LA function by speckle-tracking may become useful for risk stratification in patients with asymptomatic AS, but larger prospective studies are needed. (J Am Soc Echocardiogr 2019;32:257-66.) Keywords: Aortic stenosis, Heart failure, Left atrium, Speckle-tracking echocardiography, Risk stratification Calcific aortic stenosis (AS) is the most common cardiovascular disease after hypertension and coronary artery disease in developed countries. 1 Currently, the assessment of AS severity, symptomatic sta- tus, and left ventricular ejection fraction (LVEF) play a crucial role in the management algorithm of patients with AS. 1 Symptomatic pa- tients with severe AS have a very high mortality rate and require prompt aortic valve replacement (AVR). 1-3 Although asymptomatic patients with severe AS have a relatively benign prognosis, the risk for adverse cardiac events rises abruptly with the onset of symptoms. 4-7 Therefore, it is clinically relevant to find the correlates of heart failure (HF) symptoms in patients with severe AS and preserved LVEF who would benefit from early elective AVR. Previous studies have shown that symptomatic status in severe AS is associated with increased plasma levels of brain natriuretic peptide (BNP), smaller aortic valve area (AVA), higher degree of left ventricu- lar (LV) hypertrophy, and impaired LV diastolic function, including From the University of Medicine and Pharmacy ‘‘Carol Davila,’’ Euroecolab, (A.D.M., A.C., C.C.B., M.R., R.E., C.B., S.B., C.G., B.A.P.), and the Emergency Institute of Cardiovascular Diseases ‘‘Prof. Dr. C. C. Iliescu’’ (A.D.M., A.C., C.C.B., M.R., R.E., C.G., B.A.P.), Bucharest, Romania. This work was supported by a grant from the Romanian Ministry of National Edu- cation, CNCS – UEFISCDI, project number PN-II-ID-PCE-2012-4-0560 (contract 21/2013). Drs. Mateescu and C alin contributed equally to this study. Conflicts of Interest: Dr. Popescu has received research support and lecture hon- oraria from GE Healthcare. The other authors report no actual or potential conflicts of interest. Reprint requests: Bogdan A. Popescu, MD, PhD, University of Medicine and Phar- macy ‘‘Carol Davila,’’ Euroecolab, Emergency Institute of Cardiovascular Diseases ‘‘Prof. Dr. C. C. Iliescu,’’ Cardiology Department, Sos Fundeni 258, Sector 2, 022328 Bucharest, Romania (E-mail: bogdan.a.popescu@gmail.com). 0894-7317/$36.00 Copyright 2018 by the American Society of Echocardiography. https://doi.org/10.1016/j.echo.2018.11.007 257