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International audience; UNLABELLED: In aortic stenosis (AS), left ventricular (LV) adaptation to exercise has poorly been examined. Changes in LV ejection fraction may lack accuracy in identifying the presence of intrinsic myocardial impairment. AIMS: We sought to determine the impact of aortic stenosis (AS) on left ventricular (LV) longitudinal function at exercise in a series of asymptomatic patients with AS and preserved LV ejection fraction. METHODS AND RESULTS: Long-axis function was assessed at rest and at exercise by using 2D speckle tracking of myocardial deformation in 207 AS patients (aortic valve area 0.87 ± 0.19 cm²) and 43 aged-matched control subjects. When compared with control subjects, patients with AS have reduced longitudinal myocardial function at rest (-20.2 ± 2.7 vs. -15.4 ± 4.0%) and at peak exercise (-25.0 ± 3.7 vs. -16.5 ± 4.9%) (P < 0.0001 for both). Exercise changes in global longitudinal strain were correlated with changes in LV ejection in controls but not in patients with AS. Changes in LV global longitudinal strain during test were lower in AS patients with an abnormal response to exercise (-0.5 ± 2.7 vs. -1.5 ± 2.8%, P = 0.001). In multivariate analysis, a lower global longitudinal strain at rest (P = 0.04), a higher increase in mean trans-valvular pressure gradient (P < 0.001) at exercise, and smaller exercise-induced changes in global longitudinal strain (P < 0.001) were associated with an abnormal exercise test. CONCLUSION: In AS, subnormal LV function can be reliably identified by 2D strain imaging at rest and during a sub-maximal exercise. That sensitive measure of LV systolic function is depressed in AS and even more in patients having the most severe AS.

In patients with aortic stenosis (AS) requiring aortic valve intervention, the accurate assessment of aortic annulus and aortic root size and geometry is of high clinical interest.1 The presence of small aortic root (SAR), may complicate aortic valve procedure. Furthermore, earlier in the natural history of patients with AS, SAR per se , may make the AS severity assessment more complex, due to increase pressure recovery phenomenon. Indeed, SAR may be source of discordant findings between AS severity parameters such as aortic valve area and mean pressure gradient.2 Altogether, these points underline the challenge particularities of patients with AS and SAR in clinical practice. However, although the determinants of SAR are well known, data regarding the potential prognostic value of SAR per se for risk stratification in patients with AS are lacking. Beforehand, the exact definition of SAR and the appropriate method of assessment still remain undetermined. In this issue of the ‘Journal’, Bahlmann et al. 3 report a sub-analysis of the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. They measured, in the study core-lab, the end-diastolic inner diameters and anterior wall thicknesses of the ascending aorta at the sinus of Valsalva and sino-tubular junction levels in 1560 patients who underwent echocardiography in 173 centres. They defined SAR as aortic sino-tubular junction diameter indexed for body height