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

Objectives 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 beyond the 2025 ESC/EACTS Class I/IIb surgical decision indications among a prespecified subgroup of patients with no or minimal symptoms (NYHA functional class I–II) who were potential candidates for aortic valve replacement. Methods This retrospective cohort study included 707 patients (mean age 54.5 ± 13.5 years; 593 male) with at least moderate chronic AR who underwent CMR between 2010 and 2024. The primary endpoint was major adverse cardiac events (MACE), defined as all-cause mortality, heart transplantation, rehospitalization for heart failure, or ICD discharge. Results During a median follow-up of 52.6 months, 152 patients experienced MACE. Multivariable Cox regression identified FT-LVGLS as an independent predictor of MACE (adjusted HR: 1.148 per 1% increase, P < .001). Among patients with NYHA class I-II, incorporating FT-LVGLS into models based on each ESC/EACTS Class I/IIb surgical indication significantly improved model discrimination, with higher C-index (from 0.739-0.747 to 0.775) and likelihood ratio χ² values (from 34.00-39.18 to 46.65-47.66). Kaplan-Meier survival curves demonstrated that a cutoff of -12% for FT-LVGLS further refined risk stratification. Conclusion FT-LVGLS independently predicted adverse outcomes in patients with chronic moderate-to-severe AR, providing incremental prognostic value beyond ESC/EACTS surgical indicators and improving risk identification.