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J Am Soc Echocardiogr. 2015 Nov;28(11):1294-301. doi: 10.1016/j.echo.2015.07.029. Epub 2015 Sep 1.

Increased apical rotation in severe aortic stenosis is associated with reduced survival: a speckle-tracking study.

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Division of Cardiology, Montefiore Medical Center, Bronx, New York. Electronic address:
Division of Cardiology, Montefiore Medical Center, Bronx, New York.
Division of Cardiology, Montefiore Medical Center, Bronx, New York; Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, New York.



Patients with severe aortic stenosis (AS) are known to have increased left ventricular apical rotation (ApRot) during systole, but its clinical relevance is unknown. The aim of this study was to assess the association of ApRot with patient symptoms and total mortality.


A retrospective analysis was performed on 82 patients (mean age, 77 ± 14 years; 40% men) with newly diagnosed severe AS with indexed aortic valve areas ≤ 0.6 cm(2)/m(2) and left ventricular ejection fractions ≥ 50%. Sixty-three percent of patients were symptomatic. ApRot was calculated using speckle-tracking echocardiography. Patients were divided into two groups on the basis of ApRot: high ApRot (>4.0°, n = 41) and low ApRot (≤4.0°, n = 41).


There were 33 deaths and 30 aortic valve replacement procedures after 33 ± 17 months of follow-up. Patients in the high-ApRot group had smaller indexed aortic valve areas (P = .021) and increased valvuloarterial impedance (P = .014). There was no difference in overall symptoms, but the low-ApRot group experienced more syncope (P = .020). Patients in the high-ApRot group had reduced survival with medical therapy (log-rank P = .018) after aortic valve replacement (log-rank P = .039) and overall (log-rank P = .009). Asymptomatic patients with low ApRot had the best survival, while asymptomatic patients with high ApRot had similar survival to that of symptomatic patients (log-rank P = .008). On adjusted Cox regression, ApRot ≥ 6.0° was independently associated with death (hazard ratio, 3.06; P = .003). On receiver operating characteristic curve analysis, ApRot added incremental prognostic value to indexed aortic valve area, symptom status, and aortic valve replacement status.


Increased ApRot is independently associated with poor survival and may represent a compensatory mechanism to preserve cardiac output against severe obstruction to flow and high systolic load.


Apical rotation; Severe aortic stenosis

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