Left ventricular global longitudinal strain improves risk stratification in chronic aortic regurgitation

AIMS: To evaluate the prognostic value of cardiac magnetic resonance (CMR) feature tracking-derived left ventricular global longitudinal strain (FT-LVGLS) for adverse outcomes in patients with chronic moderate to severe aortic regurgitation (AR), and to further assess its incremental prognostic value in predicting adverse outcomes beyond the 2025 ESC/EACTS Class I/IIb surgical indication parameters. METHODS AND RESULTS: This retrospective cohort study initially screened 707 patients with at least moderate chronic AR who underwent CMR between 2010 and 2024, of whom 385 with no or minimal symptoms (NYHA class I-II; mean age 54.1 ± 13.5 years; 329 male) constituted the primary study cohort. The primary endpoint was major adverse cardiac events (MACE), defined as all-cause mortality, heart transplantation, unplanned hospitalization for heart failure, or implantable cardioverter defibrillator discharge. During a median follow-up of 52.9 months, 45 patients experienced MACE. Multivariable Cox regression identified FT-LVGLS as independently associated with MACE (adjusted HR: 1.210 per 1% decrease in absolute FT-LVGLS, P < 0.007). Incorporating FT-LVGLS into prognostic models containing each ESC/EACTS Class I/IIb surgical indication parameter (dichotomized by guideline-recommended thresholds) consistently improved model discrimination for MACE, with C-index increasing from 0.730-0.768 to 0.783-0.791 and likelihood ratio χ2 values from 36.04-41.12 to 50.10-52.07. Kaplan-Meier survival curves demonstrated that an absolute FT-LVGLS cut-off of 12% further refined risk stratification. CONCLUSION: In NYHA class I-II patients with chronic moderate-to-severe AR, FT-LVGLS was independently associated with MACE and provided incremental prognostic value beyond ESC/EACTS guideline-based surgical indication parameters, supporting its potential role in improving risk identification.