Can tissue tracking-based assessment of aortic valve displacement improve diagnostic accuracy of aortic stenosis severity in women?

Abstract Background Aortic stenosis (AS) presents distinct pathophysiological characteristics in women, including a higher proportion of valve fibrosis, more concentric left ventricular hypertrophy, and smaller ventricular cavity size. These differences contribute to a higher prevalence of normal-flow, low-gradient (NF LG) AS, necessitating a multimodal approach for accurate severity assessment. Tissue tracking (TT) applied to transthoracic echocardiography (TTE) enables quantification of longitudinal aortic valve displacement (AVD), reflecting impaired valve movement due to calcification and fibrosis. However, its diagnostic value in assessing AS severity remains underexplored. Purpose Assesment of the diagnostic performance of AVD quantified by TT for evaluating AS severity in men and women using TTE. Methods A total of 210 patients (aged 71±10 years, 42% men) with at least moderate AS who underwent TTE between 2020 and 2024 were included. Exclusion criteria were mild aortic regurgitation, mitral/tricuspid valve disease, EF ≤50%, indexed stroke volume (SVI) ≤35 mL/m², arrhythmia, and poor acoustic window. Severe AS (n=158, 34% men) was defined by an aortic valve area (AVA) ≤1.0 cm², confirmed via planimetry on transesophageal echocardiography (TOE) in discordant cases. NF LG AS (AVA ≤1.0 cm², mean gradient 40 mmHg) was identified in 42 patients (26% men). Non-severe AS (AVA 1.0 cm²) was diagnosed in 52 patients (65% men), while 48 controls (70±10 years, 48% men) with normal TTE findings were included. TT was applied in five- and three-chamber views, adjusting the region of interest to cover the entire aortic valve. Using Q- analysis software, the maximum positive curve of systolic valve excursion, representing displacement toward the apex, was measured in millimeters (Figure 1). AVD was averaged across both views. Results AVD was significantly lower in patients with severe AS (men: 9.7±1.7 mm, women: 9.5±1.6 mm) than in those with non-severe AS (men: 11.3±1.5 mm, women: 11.7±1.8 mm) and controls (men: 12.6±1.2 mm, women: 11.6±0.9 mm) (p0.001). No significant sex differences in AVD were observed within the severe and non-severe AS groups (p0.1). In women, AVD demonstrated a strong discriminative ability for severe AS, maintaining a good sensitivity-specificity balance, particularly in NF LG AS. In men, AVD exhibited good diagnostic capability but with moderate accuracy (Table 1). AVD measurements showed excellent reproducibility, with inter- and intra-observer intraclass correlation coefficients of 0.99 (95% CI: 0.98-0.99) and 0.97 (95% CI: 0.97-0.98), respectively. Conclusions AVD is a novel echocardiographic parameter that enhances the diagnostic accuracy of AS severity, particularly in women with NF LG AS on TTE.