Afterload-adjusted strain associated with outcomes in mixed aortic valve disease

BackgroundMixed aortic valve disease (MAVD) exposes the left ventricle (LV) to combined pressure and volume overload, which may not be adequately captured by conventional valve-centric parameters. We evaluated an integrated echocardiographic framework incorporating ventricular geometry and afterload-adjusted myocardial performance to better characterize LV adaptation in MAVD. MethodsWe retrospectively analyzed 950 patients with moderate or greater aortic stenosis categorized by aortic regurgitation (AR) severity. The integrated geometry index (IGI) was defined as the z-standardized sum of relative wall thickness and indexed LV end-diastolic volume. Afterload-adjusted strain (AAS) was calculated as absolute LV global longitudinal strain multiplied by estimated LV systolic pressure (systolic blood pressure + aortic valve mean pressure gradient), followed by z-standardization. The primary outcome was all-cause death or heart failure hospitalization; the secondary outcome was aortic valve replacement (AVR). ResultsDuring a median follow-up of 3.5 years, 122 primary events occurred. Increasing AR severity was associated with progressive LV remodeling and higher IGI, whereas AAS remained similar across MAVD phenotypes. IGI was associated with AVR but not with the primary outcome. In contrast, lower AAS was independently associated with the primary outcome (adjusted HR 1.59 per unit decrease, 95% CI 1.30-1.96; p<0.001) and improved discrimination beyond clinical variables (AUC 0.69 vs. 0.62). These associations were consistent across MAVD phenotypes and LV remodeling patterns. ConclusionsIn MAVD, afterload-adjusted myocardial performance provides independent and incremental prognostic value beyond structural remodeling. Incorporating AAS may improve risk stratification and complement conventional valve-centric assessment.