Longitudinal function in aortic stenosis: prognostic value of mitral plane systolic excursion.

Background

Left ventricular (LV) longitudinal function is a major prognostic determinant in aortic stenosis (AS) and is typically assessed using speckle-tracking echocardiography. Mitral annular plane systolic excursion (MAPSE) is a simple and widely available surrogate of longitudinal function; however, its prognostic value has not been prospectively validated.

Purpose

To evaluate the prognostic value of MAPSE in patients with moderate-to-severe AS.

Methods

We prospectively enrolled 203 patients with moderate (aortic valve area [AVA] 1.0–1.5 cm²) or severe AS (AVA < 1.0 cm²) and left ventricular ejection fraction (LVEF) > 50%. MAPSE was calculated as the average of septal and lateral mitral annular excursion in the apical four-chamber view. Patients were stratified according to MAPSE (< 1.18 cm vs. ≥ 1.18 cm) and LVEF (< 60% vs. ≥ 60%), defining four systolic phenotypes: Group A (MAPSE ≥ 1.18 cm and LVEF ≥ 60%), Group B (MAPSE < 1.18 cm and LVEF

≥ 60%), Group C (MAPSE ≥ 1.18 cm and LVEF < 60%), and Group D (MAPSE < 1.18 cm and LVEF <60%).The primary endpoint was a composite of aortic valve replacement (AVR) or all-cause mortality.

Results

Mean age was 71.8 ± 10.7 years, and mean LVEF was 64.4 ± 6.9%. Median MAPSE was 1.30 cm (IQR 1.09–1.44), and severe AS was present in 61.6% of patients. During a median follow-up of 24.3 months (IQR 13.8–36.5), the primary endpoint occurred in 32.5% of patients, while all-cause mortality was 11.3%. MAPSE < 1.18 cm was strongly associated with the primary endpoint (p < 0.001; HR 3.0 [1.84-4.87] Fig. 1A), as was LVEF < 60% (p < 0.001; HR 2.67 [1.62-4.40] Fig. 1B).Regarding to systolic phenotype, Group D exhibited the worst event-free survival compared with all other phenotypes (p < 0.001 vs. Group A; p = 0.008 vs. Group B; p = 0.007 vs. Group C; Fig. 1C). Compared to group A, group D has an HR of 5.78 (3.10-10.7). Notably, MAPSE < 1.18 cm was significantly associated with all-cause mortality (Fig. 2A; p = 0.003; HR 3.27 [1.41-7.56]), whereas LVEF was not (Fig. 2B; p = 0.251; HR 1.69 [0.69-4.07]). MAPSE remained predictive of the primary endpoint across LVEF strata (p = 0.004 for LVEF ≥ 60%; HR 2.39 [1.29-4.43] and p = 0.008; HR 3.23[1.29-7.58] for LVEF < 60%; Fig. 2C and 2D, respectively).

Conclusion

MAPSE is a robust and clinically meaningful prognostic marker in patients with moderate-to-severe AS, providing incremental risk stratification beyond LVEF. These findings highlight the importance of longitudinal LV function for risk stratification, independent of the assessment modality.