{"paper_id":"34971bdb-d8ee-477b-8a47-123bf66cc241","body_text":"Left Atrial Strain in Mitral Valve Disease: A Comparative Analysis of Regurgitation and Stenosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Left Atrial Strain in Mitral Valve Disease: A Comparative Analysis of Regurgitation and Stenosis Fariba Bayat, Sepideh Jame Bozorgi, Mohammad Khani, Nahid Mohebi Saeen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6408954/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Jan, 2026 Read the published version in BMC Cardiovascular Disorders → Version 1 posted 15 You are reading this latest preprint version Abstract Background Left atrial (LA) strain analysis is an emerging echocardiographic technique for assessing LA function. This study aimed to compare LA strain parameters in patients with mitral stenosis (MS) and mitral regurgitation (MR) to identify discriminators between these conditions. Methods This cross-sectional study included 44 patients with moderate-to-severe MR and 44 patients with severe-to-very severe MS, all with normal left ventricular ejection fraction. Patients with left ventricular systolic dysfunction, ischemic mitral regurgitation, or atrial fibrillation were excluded. Clinical data were collected, and LA strain analysis was performed offline using EchoPAC software. The study analyzed LA reservoir, conduit, and contractile strain components.LAstrainSR, LAstrainCD and LAstrainCT were derived and analyzed for their diagnostic performance. Data were analyzed using SPSS version 26.0, with one-way ANOVA used to compare LA strain parameters between groups. Results LAstrainCD demonstrated the highest diagnostic accuracy (81.8%) for differentiating MS from MR, making it the most reliable strain parameter. LAstrainCT showed the best performance for assessing MR severity, with a moderate accuracy of 61.5%. Conclusion this study elucidates the distinct impacts of mitral stenosis and regurgitation on left atrial function, as reflected by LA strain parameters. LAstrainCD emerges as a key discriminator between these conditions, highlighting differences in atrial remodeling due to pressure versus volume overload. Furthermore, LAstrainCT's correlation with MR severity enhances our understanding of atrial adaptation to regurgitant volume. These findings advance the knowledge of mitral valve disease pathophysiology, providing a foundation for improved diagnostic and therapeutic strategies. Left Atrial Strain Mitral Valve Disease Pathophysiology Mitral Regurgitation Mitral Stenosis Atrial Remodeling Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Left ventricular diastolic function, often overshadowed by systolic assessment, significantly impacts patient well-being, potentially leading to heart failure even with preserved ejection fraction ( 1 ). Impaired diastolic function is a strong predictor of adverse cardiovascular outcomes, emphasizing the need for early and accurate detection ( 2 , 3 ). While invasive pressure-volume loop analysis is the gold standard, its complexity limits clinical use ( 4 , 5 ). Transthoracic echocardiography (TTE) has become the primary non-invasive method for evaluating diastolic function ( 5 , 6 ). Conventional echocardiographic parameters, such as transmitral flow Doppler, tissue Doppler imaging, and left atrial volume, are commonly used but have limitations ( 7 , 8 ). Left atrial (LA) strain, a measure of atrial deformation, has emerged as a promising marker of diastolic function, especially in mitral valve disease. In mitral regurgitation (MR), LA strain varies with disease severity, showing an initial increase in mild cases followed by a decrease as the condition worsens ( 9 ). This biphasic response reflects early compensatory mechanisms and later deterioration. LA strain closely correlates with key parameters in MR, including regurgitation severity, left ventricular function, pulmonary artery pressure, and symptom presence ( 10 ). Furthermore, LA strain demonstrates an inverse relationship with left atrial fibrosis in severe MR, suggesting that reduced strain reflects structural remodeling ( 10 – 12 ). In mitral stenosis (MS), left atrial strain will show atrial myocardial deformation properties compared to healthy controls. LA assessment in MS may be valuable for clinical decision-making regarding the timing of intervention in asymptomatic patients and is also known to be a strong predictor for cardiovascular outcomes( 13 , 14 ) . Existing research has highlighted the prognostic value of left atrial strain in mitral regurgitation (MR) and mitral stenosis (MS) individually. Still, significant gaps remain in understanding its comparative role across these conditions. While studies have demonstrated that volume overload in MR preserves left atrial myocardial function better than pressure overload in MS, no direct comparison has been made to elucidate how these distinct hemodynamic stresses differentially affect atrial deformation mechanics and remodeling. This study systematically investigates how left atrial (LA) strain parameters are altered in mitral stenosis (MS) and mitral regurgitation (MR, offering a novel comparative analysis to elucidate the distinct pathophysiological impacts of pressure versus volume overload on atrial function. By measuring LA reservoir strain (LAstrainSR), conduit strain (LAstrainCD), and contraction strain (LAstrainCT) in well-defined cohorts with moderate-to-severe MR and severe-to-very severe MS, this research aims to uncover how these LA strain parameters are linked to the specific hemodynamic stresses imposed by each valve lesion and the distinctive remodeling processes in response to each condition. Ultimately, this study seeks to advance the understanding of mitral valve disease pathophysiology by revealing the diagnostic potential of LA strain parameters as markers of differential atrial remodeling in MS and MR, informing strategies for improved clinical management and therapeutic interventions. Methods Study design This cross-sectional study compared left atrial (LA) strain between patients with moderate to severe mitral regurgitation (MR) and severe to very severe mitral stenosis (MS). Setting The study was conducted at Modarres Hospital, a tertiary teaching hospital in Tehran, Iran. The hospital's cardiology department performed echocardiographic evaluations and collected clinical data. Participants The study included individuals aged 18–70 years with normal left ventricular ejection fraction (LVEF), defined as 52–72% for males and 54–74% for females, who had moderate-to-severe primary or secondary mitral regurgitation (MR) or moderate-to-severe mitral stenosis (MS) and provided informed consent. Exclusion criteria comprised patients with left ventricular systolic dysfunction, ischemic mitral regurgitation, atrial fibrillation rhythm, or those who withdrew consent during the study. This ensured a focused comparison of LA strain dynamics while controlling for confounding cardiac abnormalities. Mitral regurgitation (MR) and mitral stenosis (MS) severity were classified according to the American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines. Moderate MR was defined as an effective regurgitant orifice area (EROA) of 20–39 mm² or a regurgitant volume (RV) of 30–59 mL. Severe MR was defined as an EROA ≥ 40 mm² or an RV ≥ 60 mL. Severe MS was defined as a mitral valve area (MVA) ≤ 1.5 cm² and Very severe MS was defined as a mitral valve area (MVA) ≤ 1.0 cm² . Data sources/ measurement Clinical data were systematically collected through structured interviews and medical record reviews, with echocardiographic assessments performed using standardized protocols. Left atrial (LA) strain analysis was conducted offline via dedicated software (EPIQ CVx, Philips Healthcare). Mitral regurgitation and stenosis severity were classified according to ASE/EACVI guidelines to ensure consistent disease grading. During the reservoir phase, LA filling and stretching produce positive atrial strain, peaking at systole before mitral valve opening. Passive LA emptying (conduit phase) then occurs, marked by a negative strain curve deflection until diastasis, followed by a second deflection during atrial systole (contraction phase). Key measurements include peak atrial longitudinal strain (PALS) at the reservoir phase’s end and peak atrial contraction strain (PACS) post-P wave during active contraction. LA reservoir strain (LastrainSR) is defined as the positive strain difference between mitral valve opening and ventricular end-diastole. Conduit phase strain (LastrainCD) reflects the negative strain difference from atrial contraction onset to mitral valve opening, equaling LASr with a negative sign in atrial fibrillation. Contraction phase strain (LastrainCT), applicable only in sinus rhythm, measures the negative strain difference from ventricular end-diastole to contraction onset. Corresponding peak strain rates include pLASRr (positive, reservoir), pLASRcd (negative, conduit), and pLASRct (negative, contraction). Bias Several measures were implemented to mitigate potential bias. Selection bias was addressed through the consecutive enrollment of all eligible patients presenting within the study timeframe. Measurement bias was minimized by employing blinded analysis of echocardiographic parameters and adhering to standardized data collection protocols. These steps aimed to ensure the validity and reliability of the study findings. Study size To determine the appropriate sample size, a power analysis was conducted (α = 0.05, β = 0.2, effect size = 0.6, SD = 5), which yielded a requirement of 45 patients per group based on a t-statistic method and 44 patients per group using a z-statistic approximation; consequently, the group was designed with 44 patients in the group. Statistical methods Data from ninety-five participants, including forty-four with mitral regurgitation, forty-four with mitral stenosis, and seven with mixed pathology, were analyzed using SPSS version 26.0. Assessment of left atrial strain parameters, specifically reservoir, conduit, and contractile phases, revealed notable differences among the groups via one-way ANOVA. Results Participants The study population consisted of 95 participants: 44 with mitral stenosis (MS), 44 with mitral regurgitation (MR), and 7 with mixed pathology. The study cohort consisted of approximately 48% females and 52% males, The mean age was 58.36 (SD = 11.99) years for the MS group and 58.61 (SD = 13.39) years for the MR group. The body surface area was similar between the groups, 1.73 (SD = 0.09) and 1.74 (SD = 0.09) respectively. Descriptive data Table 1 Descriptive data Variables Mitral Stenosis Group Mean(SD) N = 44 Mitral Regurgitation Group n = 44 Total Age 58.36(11.99) 58.61(13.39) 58.49(12.64) Body surface area 1.73(0.09) 1.74(0.09) 1.74(0.09) Pathology degeneration 2(4.5%) 0 2(2.1%) flail of pmvl 0 4(9.1%) 4(4.2%) prolapse of the anterior leaflet 0 27(61.4%) 27(28.4%) thickened 2(4.5%) 2(4.5%) 4(4.2%) rheumatic 40(90.9%) 11(25%) 51(53.7%) Comorbidity Hypertension 18(40.9%) 15(34.1%) 33(34.7%) Diabetes Mellitus and hypertension 4(9.1%) 5(11.4%) 9(9.5%) None 22(50.0%) 24(54.5%) 46(48.4%) Left atrial volume index (LAVi) 50.80(11.86) 42.96(9.21) 47.03(11.13) The etiology of mitral valve disease varied significantly between the groups. In the MS group, rheumatic etiology was predominant (90.9%), while in the MR group, prolapse of the anterior leaflet was most common (61.4%). Comorbidities were also examined, with hypertension present in 40.9% of the MS group and 34.1% of the MR group; diabetes mellitus and hypertension were observed in 9.1% and 11.4%, respectively, and no comorbidities were recorded in 50.0% and 54.5% of each group respectively. The left atrial volume index (LAVi) was higher in the MS group compared to the MR group (50.80 ± 11.86 vs. 42.96 ± 9.21).(Table 1 ) Differentiating between Mitral stenosis and Mitral regurgitation Table 2 The measure of LA Strain MS Group Mean(SD) MR Group Mean(SD) Mean Difference 95%CI P-value SR 14.21(9.67) 23.11(10.44) 18.34 p < 0.001 CT -8.60(4.60) -11.98(6.23) -9.99 p < 0.001 CD -5.43(3.67) -12.97(7.17) -9.02 p < 0.001 Left atrial strain parameters showed significant differences between patients with MS and MR. LA strain in systolic reservoir phase (LAstrainSR) was significantly lower in MS patients compared to MR patients (14.21 ± 6.38 vs. 23.12 ± 10.45, p < 0.001). Contraction phase strain (LAstrainCT) was less negative in MS than MR (-8.61 ± 4.60 vs. -11.98 ± 6.24, p = 0.005). The most pronounced difference was observed in conduit phase strain (LAstrainCD), which was substantially less negative in MS patients compared to MR patients (-5.43 ± 3.68 vs. -12.98 ± 7.18, p < 0.001). Trends in strain parameters across the severity spectrum Figure 1 illustrates distinct trends in left atrial strain parameters across moderate to severe stages of mitral regurgitation (MR) and severe to very severe mitral stenosis (MS), highlighting the pathophysiological impact of these conditions on atrial function. LA reservoir strain (LAstrainSR) decreases significantly with increasing severity in both MS and MR, reflecting impaired atrial compliance and reduced ability to store blood during ventricular systole. In MS, where rheumatic etiology was predominant (90.9%), this decline is primarily driven by chronic pressure overload, which induces atrial fibrosis and stiffness. In MR, where prolapse of the anterior leaflet was most common (61.4%), the reduction in LAstrainSR is associated with progressive atrial dilatation and myocyte dysfunction due to chronic volume overload, signaling decompensation of atrial function. When comparing moderate versus severe MR patients, LAstrainSR was numerically higher in moderate MR compared to severe MR (25.07 ± 9.98 vs. 21.49 ± 10.75, p = 0.263), though this difference did not reach statistical significance. Conversely, conduit phase strain (LAstrainCD) and contraction phase strain (LAstrainCT) exhibit an upward trend (less negative values) as disease severity increases. This pattern reflects impaired passive left atrial emptying during early diastole and reduced active atrial contraction during late diastole. In MS, elevated left atrial pressure limits passive conduit flow, while fibrotic remodeling blunts active contraction. In MR, disrupted ventricular-atrial coupling compromises both phases of atrial function, leading to less effective conduit flow and reduced contractile force. Similar to LAstrainSR, LAstrainCT was more negative in moderate MR than severe MR (-13.91 ± 5.88 vs. -10.37 ± 6.18, p = 0.060), and LAstrainCD was also more negative in moderate MR compared to severe MR (-14.11 ± 9.14 vs. -12.04 ± 5.02, p = 0.347); however, neither of these differences reached statistical significance. These trends underscore the progressive nature of left atrial dysfunction in moderate-to-severe stages of MR and severe to very severe MS, where compensatory mechanisms are largely absent or overwhelmed. The decline in LAstrainSR signals worsening reservoir function, while the less negative values of LAstrainCD and LAstrainCT indicate advanced remodeling and impaired diastolic mechanics. Notably, statistical analysis reveals significantly reduced LA strain values in very severe MS compared to severe MS: LAstrainSR (10.54% vs. 16.76%), LAstrainCT (-6.52% vs. -10.05%), and LAstrainCD (-3.45% vs. -6.81%), all with p < 0.01. These findings confirm a clear downward trend in LA strain with increasing MS severity. Table 3 This table presents the mean values and statistical comparisons of left atrial (LA) strain parameters and left atrial volume index (LAVi) across different severity grades of MR and MS. LastrainSR Mean difference Confidence interval (p-value) LastrainCD Mean difference Confidence interval (p-value) LastrainCT Mean difference Confidence interval (p-value) LAVI(left atrial volume index) Mean difference Confidence interval (p-value) Moderate MR Vs Severe MS 8.31 95%(1.78,14.84) 0.007 -3.86 95%(-8.07,0.35) 0.92 -7.29 95%(-11.79,-2.79) < 0.001 -10.00 95%(-17.32,-2.68) 0.002 Moderate MR Vs Very severe MS 14.53 95%(7.17,21.88) < 0.001 -7.38 95%(-11.99,-2.78) < 0.001 -10.65 95%(-15.56,-5.74) < .001 -20.58 95%(-28.58,-12.59) < 0.001 Severe MR Vs Severe MS 4.73 95%(-1.67,-11.14) 0.29 -0.32 95%(-4.33,3.69) 1.00 -5.22 95%(-9.51,-0.94) 0.008 1.90 95%(-5.06,8.86) 1.00 Severe MR Vs Very severe MS 10.59 95%(3.89,18.00) < 0.001 -3.84 95%(-8.27,0.57) 0.12 -8.58 95%(-13.3,-3.87) < 0.001 -8.67 95%(-16.34,-1.00) 0.018 Diagnostic accuracy Our ROC curve analysis reveals that for distinguishing between MS and MR, LAstrainCD is the most valuable diagnostic parameter with excellent discrimination ability (AUC > 0.8)2. A LAstrainCD value greater than − 9.0 (less negative) provides the optimal balance between sensitivity (84.1%) and specificity (79.5%) for diagnosing MS, resulting in the highest overall diagnostic accuracy of 81.8%2. This makes LAstrainCD the most reliable individual strain parameter for discriminating between these two common mitral valve pathologies. LAstrainSR, despite having a seemingly low AUC (0.239), actually demonstrates good diagnostic performance when interpreted correctly—that is, using lower values to identify MS patients. A cutoff value of < 15.0 yields high sensitivity (77.3%) and specificity (79.5%) with an accuracy of 78.4%2. LAstrainCT shows moderate diagnostic capability with an accuracy of 69.3% at the optimal cutoff of >-10.02. For assessing MR severity, LAstrainCT demonstrates the best, albeit modest, diagnostic performance. A LAstrainCT value greater than − 11.9 (less negative) suggests severe MR with moderate sensitivity (54.2%) and specificity (70.0%), yielding an accuracy of 61.5%1. LAstrainCD and LAstrainSR show limited utility in this context, with diagnostic accuracies of 59.1% and 54.5%, respectively. However, given the borderline statistical significance (p = 0.090) and modest AUC (0.650) for LAstrainCT, LA strain parameters appear to have limited utility in distinguishing moderate from severe MR when used alone. Table 1. summarizes the diagnostic performance and optimal cut-off values for LA strain measures in differentiating MS from MR and assessing MR severity. Table 4 Parameter Application AUC (95% CI) p-value Optimal Cut-off Sensitivity Specificity LAstrainSR MS vs MR 0.239 (0.135–0.342) < 0.001 < 15.0* 77.30% 79.50% LAstrainCT MS vs MR 0.658 (0.542–0.773) 0.011 >-10.0* 72.70% 65.90% LAstrainCD MS vs MR 0.815 (0.720–0.910) < 0.001 >-9.0* 84.10% 79.50% LAstrainSR MR Severity 0.410 (0.239–0.582) 0.311 < 22.3 50.00% 60.00% LAstrainCT MR Severity 0.650 (0.487–0.813) 0.09 >-11.9 54.20% 70.00% LAstrainCD MR Severity 0.585 (0.403–0.768) 0.334 >-12.6 54.20% 65.00% *For differentiating MS from MR, a value less than the cut-off for LAstrainSR and values greater than (less negative) the cut-offs for LAstrainCT and LAstrainCD suggest MS. Discussion Based on our study, left atrial (LA) strain analysis provides valuable insights into the distinct pathophysiological mechanisms underlying mitral stenosis (MS) and mitral regurgitation (MR). The superior diagnostic accuracy of LA conduit strain (LAstrainCD) in differentiating MS from MR (81.8%) underscores the divergent atrial remodeling processes in these conditions, reflecting how the LA adapts differently to pressure overload in MS versus volume overload in MR. The finding that LAstrainCT best assesses MR severity (61.5% accuracy) sheds light on how progressive LA dysfunction occurs as the atrial myocardium struggles to compensate for increasing regurgitant volume. These observations advance our understanding of the unique hemodynamic stresses imposed by MS and MR, and how these stresses lead to specific patterns of LA deformation and functional impairment. By elucidating these differential effects on LA strain, our research contributes to a more comprehensive understanding of the pathophysiology of mitral valve diseases. Building upon this, our findings align with the established understanding of LA dysfunction in MS and MR. Prior research consistently reveals impaired global LA strain in MS patients compared to healthy controls, with severe cases exhibiting average values around 13.4 ± 0.75% ( 15 ), and some recent studies reporting even lower peak atrial longitudinal strain (PALS) measurements, averaging approximately 8.2% ( 16 ). In contrast, MR patients generally show a less pronounced reduction in global LA strain, with PALS averaging around 15.2% ( 16 ). While global strain differences offer some discriminatory power, more nuanced variations emerge when analyzing specific strain components and strain rate parameters, as demonstrated by Alves et al( 17 ). Notably, Alves et al. specifically compared LA strain parameters in MS and MR patients, finding that systolic and early diastolic strain rates were better preserved in MR, while late diastolic strain rate was more impaired, highlighting the differential impact of these conditions on LA function. This study reveals distinct LA strain patterns in mitral stenosis (MS) and mitral regurgitation (MR), highlighting their value in characterizing the pathophysiological impact of each condition on atrial function. While LA reservoir strain (LAstrainSR) decreases with increasing severity in both MS and MR, LA conduit (LAstrainCD) and contraction strain (LAstrainCT) exhibit less negative values as severity increases. Also, LAstrainCT shows modest value in differentiating the severity of MR (AUC = 0.650). These findings underscore the potential of LA strain analysis to provide insights into differential atrial remodeling in MS and MR, informing improved diagnostic and therapeutic strategies. However, to the best of our knowledge, no prior study has specifically focused on elaborating the distinct pathophysiology of LA remodeling in MS and MR in a comparative manner using LA strain parameters. Our study uniquely addresses this gap by demonstrating how LA strain parameters can be utilized to understand and differentiate the distinct atrial remodeling processes driven by pressure overload in MS and volume overload in MR. Building upon the diagnostic utility of LA strain analysis and its ability to differentiate between MS and MR, it's crucial to consider the clinical value of these measurements in the broader context of mitral valve disease management. Left atrial strain measurements have emerged as important prognostic indicators, offering insights beyond conventional parameters like LA volume. In patients with mitral regurgitation, peak atrial longitudinal strain (PALS) has proven particularly valuable, identifying left atrial dysfunction even in asymptomatic patients and correlating with atrial fibrosis, remodeling, and long-term survival after valve surgery ( 18 ). PALS measurements serve as significant predictors of atrial fibrillation development and cardiovascular outcomes in patients with mitral valve disease ( 19 , 20 ). In fact, studies have demonstrated that reduced PALS values are strongly associated with the onset of atrial fibrillation, as impaired reservoir function reflects underlying structural remodeling and fibrosis within the left atrium( 21 ). Furthermore, preoperative LA strain imaging provides valuable information for predicting outcomes after surgical interventions, including the degree of LA fibrosis and remodeling after mitral valve replacement( 22 , 23 ). Finally, assessing LA strain parameters before and after interventions like PTMC and MVR in patients with mitral stenosis can help guide decision-making regarding timing and type of intervention, as well as predict the likelihood of maintaining sinus rhythm post-procedure ( 19 ). While our study focuses on the differential diagnostic capabilities of specific LA strain parameters in MS and MR, the existing literature underscores the broader clinical utility of LA strain as a prognostic marker and a tool for guiding treatment strategies in patients with mitral valve disease. While our findings demonstrate the potential of LAstrainCD in differentiating MS from MR and LAstrain CT in assessing MR severity, it's essential to acknowledge the limitations that affect the generalizability of our results. The study population, while carefully selected based on specific inclusion and exclusion criteria, may not fully represent the broader spectrum of patients with mitral valve disease. For instance, the exclusion of patients with significant co-morbidities like severe coronary artery disease, other significant valvular lesions, or advanced heart failure, limits the applicability of our findings to patients with relatively isolated MS or MR. Additionally, the single-center design and relatively modest sample size may introduce selection bias and limit the statistical power to detect more subtle differences in LA strain parameters. Further research involving larger, multi-center cohorts with more diverse patient populations is needed to validate these findings and establish the clinical utility of LAstrainCD and LAstrainCT in routine clinical practice. Future research should focus on addressing the limitations of the current study and expanding our understanding of LA strain in mitral valve disease. Specifically, investigations incorporating patients with a wider range of co-morbidities and disease severity are warranted. Furthermore, longitudinal studies assessing the prognostic value of LAstrainCD and LAstrainCT in predicting clinical outcomes, such as atrial fibrillation, heart failure hospitalization, and mortality, would provide valuable insights into the long-term clinical implications of LA dysfunction in MS and MR. Finally, exploring the incremental value of LA strain analysis in combination with other established echocardiographic parameters and biomarkers could further refine risk stratification and guide personalized treatment strategies for patients with mitral valve disease. Investigating the impact of different treatment strategies (e.g., medical management, percutaneous interventions, surgical repair/replacement) on LA strain parameters and clinical outcomes would also be of significant clinical relevance. Further research needed to use AI based analysis to improve diagnostic value of LA strain in such conditions Abbreviations LA Left Atrium/Left Atrial MS Mitral Stenosis MR Mitral Regurgitation LVEF Left Ventricular Ejection Fraction ASE American Society of Echocardiography EACVI European Association of Cardiovascular Imaging EROA Effective Regurgitant Orifice Area RV Regurgitant Volume MVA Mitral Valve Area TTE Transthoracic Echocardiography LAstrainSR LA reservoir strain LAstrainCD Conduit phase strain LAstrainCT Contraction phase strain pLASRr peak atrial longitudinal strain rate (positive, reservoir) pLASRcd peak atrial longitudinal strain rate (negative, conduit) pLASRct peak atrial longitudinal strain rate (negative, contraction) LAVi Left Atrial Volume Index PACS Peak atrial contraction strain PALS Peak atrial longitudinal strain SPSS Statistical Package for the Social Sciences ANOVA analysis of variance ROC Receiver Operating Characteristic Declarations Ethics Approval and Consent to Participate This study was reviewed and approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran (Approval Number: IRSBMU.RETECH.REC.1403.316). Written informed consent was obtained from all participants prior to their inclusion in the study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Consent for Publication Not applicable (as no individual patient data is presented). Availability of Data and Materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no conflicts of interest. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' Contributions Fariba Bayat: Data collection, manuscript writing. Sepideh Jame Bozorgi: Data collection, manuscript writing and analysis. 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Speckle tracking echocardiography in primary mitral regurgitation: should we reconsider the time for intervention? Heart Failure Reviews. 2021;27:1247 - 60. Malik V, Subramaniam A, Kapoor PM. Strain and strain rate: An emerging technology in the perioperative period. Annals of Cardiac Anaesthesia. 2016;19:112 - 21. Her A-Y, Choi E-Y, Shim CY, Song BW, Lee S, Ha J-W, et al. Prediction of Left Atrial Fibrosis With Speckle Tracking Echocardiography in Mitral Valve Disease: A Comparative Study With Histopathology. Korean Circulation Journal. 2012;42:311 - 8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Jan, 2026 Read the published version in BMC Cardiovascular Disorders → Version 1 posted Editorial decision: Revision requested 20 Aug, 2025 Reviews received at journal 14 Aug, 2025 Reviewers agreed at journal 29 Jul, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviewers agreed at journal 24 Jul, 2025 Reviewers agreed at journal 24 Jul, 2025 Reviewers agreed at journal 14 May, 2025 Reviewers agreed at journal 11 May, 2025 Reviews received at journal 08 May, 2025 Reviewers agreed at journal 01 May, 2025 Reviewers invited by journal 30 Apr, 2025 Editor assigned by journal 24 Apr, 2025 Editor invited by journal 21 Apr, 2025 Submission checks completed at journal 18 Apr, 2025 First submitted to journal 18 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6408954\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":450529247,\"identity\":\"a03b49b1-1790-475b-adc4-9f2530f2a789\",\"order_by\":0,\"name\":\"Fariba Bayat\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Shahid Beheshti University of Medical Sciences\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Fariba\",\"middleName\":\"\",\"lastName\":\"Bayat\",\"suffix\":\"\"},{\"id\":450529248,\"identity\":\"19031a08-ac30-4dec-a4f7-096cb517183c\",\"order_by\":1,\"name\":\"Sepideh Jame Bozorgi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Shahid Beheshti University of Medical Sciences\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Sepideh\",\"middleName\":\"Jame\",\"lastName\":\"Bozorgi\",\"suffix\":\"\"},{\"id\":450529249,\"identity\":\"ea2a3bdf-1920-463f-94d5-ed27053285ec\",\"order_by\":2,\"name\":\"Mohammad Khani\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Shahid Beheshti University of Medical Sciences\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mohammad\",\"middleName\":\"\",\"lastName\":\"Khani\",\"suffix\":\"\"},{\"id\":450529250,\"identity\":\"01126ccf-9630-4941-9065-bff50ba33bd1\",\"order_by\":3,\"name\":\"Nahid Mohebi Saeen\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYDCCA1DSgJkZxJSQIUULWwJICw8JWhh4DEAswlr4bh9ge3Sj4o6cOTvP51c3aix4GNgPH92AT4vkuQR245wzz4wtm3m3WeccAzqMJy3tBj4tBmcY2KRz2w4nbjjMu804hw2oRYLHjCgt9RsO8zwzzvlHgpYEg8M8zI9z24jQInmGsU0658xhw53NbGbMuX0SPGyE/MJ3hvmYdE7FYXlz/sOPP+d8q5PjZz98DK8WBgbGBhiLTQJM4leOCpg/kKJ6FIyCUTAKRg4AAOFURi71Kqi2AAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Shahid Beheshti University of Medical Sciences\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Nahid\",\"middleName\":\"Mohebi\",\"lastName\":\"Saeen\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-04-09 07:08:21\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-6408954/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-6408954/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s12872-025-05427-8\",\"type\":\"published\",\"date\":\"2026-01-26T15:59:25+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":82278320,\"identity\":\"8e793582-ce14-462b-b81c-df6d5c41022d\",\"added_by\":\"auto\",\"created_at\":\"2025-05-08 14:55:20\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":102755,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThis composite figure presents the mean values of left atrial strain during the reservoir (SR), conduit (CT), and contractile (CD) phases, as well as left atrial volume index (LAVi), across increasing disease severity (moderate, severe, very severe) in patients with mitral regurgitation (MR, blue) and mitral stenosis (MS, red). Error bars represent 95% confidence intervals, highlighting group differences and trends in atrial function and remodeling with disease progression.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6408954/v1/7d18cd4b2e7a2e238a76e3ab.png\"},{\"id\":82278319,\"identity\":\"0462b269-91b0-409f-a010-ffe2a4a13472\",\"added_by\":\"auto\",\"created_at\":\"2025-05-08 14:55:20\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":63316,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eReceiver Operating Characteristic (ROC) curves for LAstrainSR (blue), LAstrainCT (pink), and LAstrainCD (green) in assessing the severity of mitral stenosis. The diagonal line (orange) represents the line of no discrimination.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6408954/v1/689dfe47e262dc5cd80c3d70.png\"},{\"id\":82276703,\"identity\":\"756f98e5-71f4-4d8a-9c8c-ea2170187905\",\"added_by\":\"auto\",\"created_at\":\"2025-05-08 14:47:20\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":62637,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eReceiver Operating Characteristic (ROC) curves for LAstrainSR (blue), LAstrainCT (pink), and LAstrainCD (green) in assessing the severity of mitral regurgitation. The diagonal line (orange) represents the line of no discrimination.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6408954/v1/5378bb0b591bc8ba3fe383f8.png\"},{\"id\":82279356,\"identity\":\"81988e57-d733-417f-9276-d293dd0dbef4\",\"added_by\":\"auto\",\"created_at\":\"2025-05-08 15:03:20\",\"extension\":\"png\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":65036,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eReceiver Operating Characteristic (ROC) curves illustrating the diagnostic accuracy of LAstrainSR (blue), LAstrainCT (pink), and LAstrainCD (green) in differentiating between mitral stenosis (MS) and mitral regurgitation (MR). The diagonal line (orange) indicates the line of chance discrimination.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6408954/v1/98a0e11cbc7e9e4afa5149cf.png\"},{\"id\":101690791,\"identity\":\"781412e0-c722-4c34-8ee2-0a695f96724a\",\"added_by\":\"auto\",\"created_at\":\"2026-02-02 16:08:43\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":970291,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6408954/v1/68b8b747-c63a-43e4-8d4c-b4c8b95fa96d.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"\\u003cp\\u003eLeft Atrial Strain in Mitral Valve Disease: A Comparative Analysis of Regurgitation and Stenosis\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eLeft ventricular diastolic function, often overshadowed by systolic assessment, significantly impacts patient well-being, potentially leading to heart failure even with preserved ejection fraction (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). Impaired diastolic function is a strong predictor of adverse cardiovascular outcomes, emphasizing the need for early and accurate detection (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). While invasive pressure-volume loop analysis is the gold standard, its complexity limits clinical use (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eTransthoracic echocardiography (TTE) has become the primary non-invasive method for evaluating diastolic function (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). Conventional echocardiographic parameters, such as transmitral flow Doppler, tissue Doppler imaging, and left atrial volume, are commonly used but have limitations (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eLeft atrial (LA) strain, a measure of atrial deformation, has emerged as a promising marker of diastolic function, especially in mitral valve disease. In mitral regurgitation (MR), LA strain varies with disease severity, showing an initial increase in mild cases followed by a decrease as the condition worsens (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). This biphasic response reflects early compensatory mechanisms and later deterioration.\\u003c/p\\u003e \\u003cp\\u003eLA strain closely correlates with key parameters in MR, including regurgitation severity, left ventricular function, pulmonary artery pressure, and symptom presence (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Furthermore, LA strain demonstrates an inverse relationship with left atrial fibrosis in severe MR, suggesting that reduced strain reflects structural remodeling (\\u003cspan additionalcitationids=\\\"CR11\\\" citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e–\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eIn mitral stenosis (MS), left atrial strain will show atrial myocardial deformation properties compared to healthy controls. LA assessment in MS may be valuable for clinical decision-making regarding the timing of intervention in asymptomatic patients and is also known to be a strong predictor for cardiovascular outcomes(\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e) .\\u003c/p\\u003e \\u003cp\\u003eExisting research has highlighted the prognostic value of left atrial strain in mitral regurgitation (MR) and mitral stenosis (MS) individually. Still, significant gaps remain in understanding its comparative role across these conditions. While studies have demonstrated that volume overload in MR preserves left atrial myocardial function better than pressure overload in MS, no direct comparison has been made to elucidate how these distinct hemodynamic stresses differentially affect atrial deformation mechanics and remodeling.\\u003c/p\\u003e \\u003cp\\u003eThis study systematically investigates how left atrial (LA) strain parameters are altered in mitral stenosis (MS) and mitral regurgitation (MR, offering a novel comparative analysis to elucidate the distinct pathophysiological impacts of pressure versus volume overload on atrial function. By measuring LA reservoir strain (LAstrainSR), conduit strain (LAstrainCD), and contraction strain (LAstrainCT) in well-defined cohorts with moderate-to-severe MR and severe-to-very severe MS, this research aims to uncover how these LA strain parameters are linked to the specific hemodynamic stresses imposed by each valve lesion and the distinctive remodeling processes in response to each condition. Ultimately, this study seeks to advance the understanding of mitral valve disease pathophysiology by revealing the diagnostic potential of LA strain parameters as markers of differential atrial remodeling in MS and MR, informing strategies for improved clinical management and therapeutic interventions.\\u003c/p\\u003e \"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eStudy design\\u003c/p\\u003e\\u003cp\\u003eThis cross-sectional study compared left atrial (LA) strain between patients with moderate to severe mitral regurgitation (MR) and severe to very severe mitral stenosis (MS).\\u003c/p\\u003e\\u003cp\\u003eSetting\\u003c/p\\u003e\\u003cp\\u003eThe study was conducted at Modarres Hospital, a tertiary teaching hospital in Tehran, Iran. The hospital's cardiology department performed echocardiographic evaluations and collected clinical data.\\u003c/p\\u003e\\u003cp\\u003eParticipants\\u003c/p\\u003e\\u003cp\\u003eThe study included individuals aged 18–70 years with normal left ventricular ejection fraction (LVEF), defined as 52–72% for males and 54–74% for females, who had moderate-to-severe primary or secondary mitral regurgitation (MR) or moderate-to-severe mitral stenosis (MS) and provided informed consent. Exclusion criteria comprised patients with left ventricular systolic dysfunction, ischemic mitral regurgitation, atrial fibrillation rhythm, or those who withdrew consent during the study. This ensured a focused comparison of LA strain dynamics while controlling for confounding cardiac abnormalities.\\u003c/p\\u003e\\u003cp\\u003e Mitral regurgitation (MR) and mitral stenosis (MS) severity were classified according to the American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines. Moderate MR was defined as an effective regurgitant orifice area (EROA) of 20–39 mm² or a regurgitant volume (RV) of 30–59 mL. Severe MR was defined as an EROA ≥ 40 mm² or an RV ≥ 60 mL. Severe MS was defined as a mitral valve area (MVA) ≤ 1.5 cm² and Very severe MS was defined as a mitral valve area (MVA) ≤ 1.0 cm² .\\u003c/p\\u003e\\u003cp\\u003eData sources/ measurement\\u003c/p\\u003e\\u003cp\\u003eClinical data were systematically collected through structured interviews and medical record reviews, with echocardiographic assessments performed using standardized protocols. Left atrial (LA) strain analysis was conducted offline via dedicated software (EPIQ CVx, Philips Healthcare).\\u003c/p\\u003e\\u003cp\\u003e Mitral regurgitation and stenosis severity were classified according to ASE/EACVI guidelines to ensure consistent disease grading. During the reservoir phase, LA filling and stretching produce positive atrial strain, peaking at systole before mitral valve opening. Passive LA emptying (conduit phase) then occurs, marked by a negative strain curve deflection until diastasis, followed by a second deflection during atrial systole (contraction phase). Key measurements include peak atrial longitudinal strain (PALS) at the reservoir phase’s end and peak atrial contraction strain (PACS) post-P wave during active contraction. LA reservoir strain (LastrainSR) is defined as the positive strain difference between mitral valve opening and ventricular end-diastole. Conduit phase strain (LastrainCD) reflects the negative strain difference from atrial contraction onset to mitral valve opening, equaling LASr with a negative sign in atrial fibrillation. Contraction phase strain (LastrainCT), applicable only in sinus rhythm, measures the negative strain difference from ventricular end-diastole to contraction onset. Corresponding peak strain rates include pLASRr (positive, reservoir), pLASRcd (negative, conduit), and pLASRct (negative, contraction).\\u003c/p\\u003e\\u003cp\\u003eBias\\u003c/p\\u003e\\u003cp\\u003eSeveral measures were implemented to mitigate potential bias. Selection bias was addressed through the consecutive enrollment of all eligible patients presenting within the study timeframe. Measurement bias was minimized by employing blinded analysis of echocardiographic parameters and adhering to standardized data collection protocols. These steps aimed to ensure the validity and reliability of the study findings.\\u003c/p\\u003e\\u003cp\\u003eStudy size\\u003c/p\\u003e\\u003cp\\u003eTo determine the appropriate sample size, a power analysis was conducted (α = 0.05, β = 0.2, effect size = 0.6, SD = 5), which yielded a requirement of 45 patients per group based on a t-statistic method and 44 patients per group using a z-statistic approximation; consequently, the group was designed with 44 patients in the group.\\u003c/p\\u003e\\u003cp\\u003eStatistical methods\\u003c/p\\u003e\\u003cp\\u003eData from ninety-five participants, including forty-four with mitral regurgitation, forty-four with mitral stenosis, and seven with mixed pathology, were analyzed using SPSS version 26.0. Assessment of left atrial strain parameters, specifically reservoir, conduit, and contractile phases, revealed notable differences among the groups via one-way ANOVA.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eParticipants\\u003c/p\\u003e \\u003cp\\u003eThe study population consisted of 95 participants: 44 with mitral stenosis (MS), 44 with mitral regurgitation (MR), and 7 with mixed pathology. The study cohort consisted of approximately 48% females and 52% males, The mean age was 58.36 (SD\\u0026thinsp;=\\u0026thinsp;11.99) years for the MS group and 58.61 (SD\\u0026thinsp;=\\u0026thinsp;13.39) years for the MR group. The body surface area was similar between the groups, 1.73 (SD\\u0026thinsp;=\\u0026thinsp;0.09) and 1.74 (SD\\u0026thinsp;=\\u0026thinsp;0.09) respectively.\\u003c/p\\u003e \\u003cp\\u003eDescriptive data\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDescriptive data\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eVariables\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMitral Stenosis Group\\u003c/p\\u003e \\u003cp\\u003eMean(SD)\\u003c/p\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;44\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eMitral Regurgitation Group\\u003c/p\\u003e \\u003cp\\u003en\\u0026thinsp;=\\u0026thinsp;44\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTotal\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eAge\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e58.36(11.99)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e58.61(13.39)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e58.49(12.64)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eBody surface area\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.73(0.09)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1.74(0.09)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1.74(0.09)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"4\\\" rowspan=\\\"5\\\"\\u003e \\u003cp\\u003ePathology\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003edegeneration\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2(4.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2(2.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eflail of pmvl\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4(9.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e4(4.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eprolapse of the anterior leaflet\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e27(61.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e27(28.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ethickened\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2(4.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2(4.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e4(4.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003erheumatic\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e40(90.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11(25%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e51(53.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003eComorbidity\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHypertension\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e18(40.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e15(34.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e33(34.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDiabetes Mellitus and hypertension\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4(9.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e5(11.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e9(9.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNone\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e22(50.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e24(54.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e46(48.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLeft atrial volume index (LAVi)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e50.80(11.86)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e42.96(9.21)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e47.03(11.13)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe etiology of mitral valve disease varied significantly between the groups. In the MS group, rheumatic etiology was predominant (90.9%), while in the MR group, prolapse of the anterior leaflet was most common (61.4%). Comorbidities were also examined, with hypertension present in 40.9% of the MS group and 34.1% of the MR group; diabetes mellitus and hypertension were observed in 9.1% and 11.4%, respectively, and no comorbidities were recorded in 50.0% and 54.5% of each group respectively. The left atrial volume index (LAVi) was higher in the MS group compared to the MR group (50.80\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;11.86 vs. 42.96\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;9.21).(Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eDifferentiating between Mitral stenosis and Mitral regurgitation\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe measure of LA Strain\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMS Group\\u003c/p\\u003e \\u003cp\\u003eMean(SD)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMR Group\\u003c/p\\u003e \\u003cp\\u003eMean(SD)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eMean Difference\\u003c/p\\u003e \\u003cp\\u003e95%CI\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eP-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e14.21(9.67)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e23.11(10.44)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e18.34\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ep\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-8.60(4.60)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-11.98(6.23)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-9.99\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ep\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-5.43(3.67)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-12.97(7.17)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-9.02\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ep\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eLeft atrial strain parameters showed significant differences between patients with MS and MR. LA strain in systolic reservoir phase (LAstrainSR) was significantly lower in MS patients compared to MR patients (14.21\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;6.38 vs. 23.12\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;10.45, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Contraction phase strain (LAstrainCT) was less negative in MS than MR (-8.61\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.60 vs. -11.98\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;6.24, p\\u0026thinsp;=\\u0026thinsp;0.005). The most pronounced difference was observed in conduit phase strain (LAstrainCD), which was substantially less negative in MS patients compared to MR patients (-5.43\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.68 vs. -12.98\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;7.18, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001).\\u003c/p\\u003e \\u003cp\\u003eTrends in strain parameters across the severity spectrum\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eFigure \\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e illustrates distinct trends in left atrial strain parameters across moderate to severe stages of mitral regurgitation (MR) and severe to very severe mitral stenosis (MS), highlighting the pathophysiological impact of these conditions on atrial function. LA reservoir strain (LAstrainSR) decreases significantly with increasing severity in both MS and MR, reflecting impaired atrial compliance and reduced ability to store blood during ventricular systole. In MS, where rheumatic etiology was predominant (90.9%), this decline is primarily driven by chronic pressure overload, which induces atrial fibrosis and stiffness. In MR, where prolapse of the anterior leaflet was most common (61.4%), the reduction in LAstrainSR is associated with progressive atrial dilatation and myocyte dysfunction due to chronic volume overload, signaling decompensation of atrial function. When comparing moderate versus severe MR patients, LAstrainSR was numerically higher in moderate MR compared to severe MR (25.07\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;9.98 vs. 21.49\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;10.75, p\\u0026thinsp;=\\u0026thinsp;0.263), though this difference did not reach statistical significance.\\u003c/p\\u003e \\u003cp\\u003eConversely, conduit phase strain (LAstrainCD) and contraction phase strain (LAstrainCT) exhibit an upward trend (less negative values) as disease severity increases. This pattern reflects impaired passive left atrial emptying during early diastole and reduced active atrial contraction during late diastole. In MS, elevated left atrial pressure limits passive conduit flow, while fibrotic remodeling blunts active contraction. In MR, disrupted ventricular-atrial coupling compromises both phases of atrial function, leading to less effective conduit flow and reduced contractile force. Similar to LAstrainSR, LAstrainCT was more negative in moderate MR than severe MR (-13.91\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5.88 vs. -10.37\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;6.18, p\\u0026thinsp;=\\u0026thinsp;0.060), and LAstrainCD was also more negative in moderate MR compared to severe MR (-14.11\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;9.14 vs. -12.04\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5.02, p\\u0026thinsp;=\\u0026thinsp;0.347); however, neither of these differences reached statistical significance.\\u003c/p\\u003e \\u003cp\\u003eThese trends underscore the progressive nature of left atrial dysfunction in moderate-to-severe stages of MR and severe to very severe MS, where compensatory mechanisms are largely absent or overwhelmed. The decline in LAstrainSR signals worsening reservoir function, while the less negative values of LAstrainCD and LAstrainCT indicate advanced remodeling and impaired diastolic mechanics. Notably, statistical analysis reveals significantly reduced LA strain values in very severe MS compared to severe MS: LAstrainSR (10.54% vs. 16.76%), LAstrainCT (-6.52% vs. -10.05%), and LAstrainCD (-3.45% vs. -6.81%), all with p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01. These findings confirm a clear downward trend in LA strain with increasing MS severity.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eThis table presents the mean values and statistical comparisons of left atrial (LA) strain parameters and left atrial volume index (LAVi) across different severity grades of MR and MS.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eLastrainSR\\u003c/p\\u003e \\u003cp\\u003eMean difference\\u003c/p\\u003e \\u003cp\\u003eConfidence interval\\u003c/p\\u003e \\u003cp\\u003e(p-value)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eLastrainCD\\u003c/p\\u003e \\u003cp\\u003eMean difference\\u003c/p\\u003e \\u003cp\\u003eConfidence interval\\u003c/p\\u003e \\u003cp\\u003e(p-value)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eLastrainCT\\u003c/p\\u003e \\u003cp\\u003eMean difference\\u003c/p\\u003e \\u003cp\\u003eConfidence interval\\u003c/p\\u003e \\u003cp\\u003e(p-value)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLAVI(left atrial volume index)\\u003c/p\\u003e \\u003cp\\u003eMean difference\\u003c/p\\u003e \\u003cp\\u003eConfidence interval\\u003c/p\\u003e \\u003cp\\u003e(p-value)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModerate MR\\u003c/p\\u003e \\u003cp\\u003eVs\\u003c/p\\u003e \\u003cp\\u003eSevere MS\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8.31\\u003c/p\\u003e \\u003cp\\u003e95%(1.78,14.84)\\u003c/p\\u003e \\u003cp\\u003e0.007\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-3.86\\u003c/p\\u003e \\u003cp\\u003e95%(-8.07,0.35)\\u003c/p\\u003e \\u003cp\\u003e0.92\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-7.29\\u003c/p\\u003e \\u003cp\\u003e95%(-11.79,-2.79)\\u003c/p\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-10.00\\u003c/p\\u003e \\u003cp\\u003e95%(-17.32,-2.68)\\u003c/p\\u003e \\u003cp\\u003e0.002\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModerate MR\\u003c/p\\u003e \\u003cp\\u003eVs\\u003c/p\\u003e \\u003cp\\u003eVery severe MS\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e14.53\\u003c/p\\u003e \\u003cp\\u003e95%(7.17,21.88)\\u003c/p\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-7.38\\u003c/p\\u003e \\u003cp\\u003e95%(-11.99,-2.78)\\u003c/p\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-10.65\\u003c/p\\u003e \\u003cp\\u003e95%(-15.56,-5.74)\\u003c/p\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-20.58\\u003c/p\\u003e \\u003cp\\u003e95%(-28.58,-12.59)\\u003c/p\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSevere MR\\u003c/p\\u003e \\u003cp\\u003eVs\\u003c/p\\u003e \\u003cp\\u003eSevere MS\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4.73\\u003c/p\\u003e \\u003cp\\u003e95%(-1.67,-11.14)\\u003c/p\\u003e \\u003cp\\u003e0.29\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-0.32\\u003c/p\\u003e \\u003cp\\u003e95%(-4.33,3.69)\\u003c/p\\u003e \\u003cp\\u003e1.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-5.22\\u003c/p\\u003e \\u003cp\\u003e95%(-9.51,-0.94)\\u003c/p\\u003e \\u003cp\\u003e0.008\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1.90\\u003c/p\\u003e \\u003cp\\u003e95%(-5.06,8.86)\\u003c/p\\u003e \\u003cp\\u003e1.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSevere MR\\u003c/p\\u003e \\u003cp\\u003eVs\\u003c/p\\u003e \\u003cp\\u003eVery severe MS\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10.59\\u003c/p\\u003e \\u003cp\\u003e95%(3.89,18.00)\\u003c/p\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-3.84\\u003c/p\\u003e \\u003cp\\u003e95%(-8.27,0.57)\\u003c/p\\u003e \\u003cp\\u003e0.12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-8.58\\u003c/p\\u003e \\u003cp\\u003e95%(-13.3,-3.87)\\u003c/p\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-8.67\\u003c/p\\u003e \\u003cp\\u003e95%(-16.34,-1.00)\\u003c/p\\u003e \\u003cp\\u003e0.018\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eDiagnostic accuracy\\u003c/p\\u003e \\u003cp\\u003eOur ROC curve analysis reveals that for distinguishing between MS and MR, LAstrainCD is the most valuable diagnostic parameter with excellent discrimination ability (AUC\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.8)2. A LAstrainCD value greater than \\u0026minus;\\u0026thinsp;9.0 (less negative) provides the optimal balance between sensitivity (84.1%) and specificity (79.5%) for diagnosing MS, resulting in the highest overall diagnostic accuracy of 81.8%2. This makes LAstrainCD the most reliable individual strain parameter for discriminating between these two common mitral valve pathologies.\\u003c/p\\u003e \\u003cp\\u003eLAstrainSR, despite having a seemingly low AUC (0.239), actually demonstrates good diagnostic performance when interpreted correctly\\u0026mdash;that is, using lower values to identify MS patients. A cutoff value of \\u0026lt;\\u0026thinsp;15.0 yields high sensitivity (77.3%) and specificity (79.5%) with an accuracy of 78.4%2. LAstrainCT shows moderate diagnostic capability with an accuracy of 69.3% at the optimal cutoff of \\u0026gt;-10.02.\\u003c/p\\u003e \\u003cp\\u003eFor assessing MR severity, LAstrainCT demonstrates the best, albeit modest, diagnostic performance. A LAstrainCT value greater than \\u0026minus;\\u0026thinsp;11.9 (less negative) suggests severe MR with moderate sensitivity (54.2%) and specificity (70.0%), yielding an accuracy of 61.5%1. LAstrainCD and LAstrainSR show limited utility in this context, with diagnostic accuracies of 59.1% and 54.5%, respectively. However, given the borderline statistical significance (p\\u0026thinsp;=\\u0026thinsp;0.090) and modest AUC (0.650) for LAstrainCT, LA strain parameters appear to have limited utility in distinguishing moderate from severe MR when used alone.\\u003c/p\\u003e \\u003cp\\u003eTable 1. summarizes the diagnostic performance and optimal cut-off values for LA strain measures in differentiating MS from MR and assessing MR severity.\\u003c/p\\u003e\\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003e\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003c/div\\u003e\\u003cp\\u003e \\u003cem\\u003eTable\\u0026nbsp;4\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"7\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParameter\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eApplication\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAUC (95% CI)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eOptimal Cut-off\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eSensitivity\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eSpecificity\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLAstrainSR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMS vs MR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.239 (0.135\\u0026ndash;0.342)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;15.0*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e77.30%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e79.50%\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLAstrainCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMS vs MR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.658 (0.542\\u0026ndash;0.773)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.011\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u0026gt;-10.0*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e72.70%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e65.90%\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLAstrainCD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMS vs MR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.815 (0.720\\u0026ndash;0.910)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u0026gt;-9.0*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e84.10%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e79.50%\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLAstrainSR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMR Severity\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.410 (0.239\\u0026ndash;0.582)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.311\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;22.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e50.00%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e60.00%\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLAstrainCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMR Severity\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.650 (0.487\\u0026ndash;0.813)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.09\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u0026gt;-11.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e54.20%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e70.00%\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLAstrainCD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMR Severity\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.585 (0.403\\u0026ndash;0.768)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.334\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u0026gt;-12.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e54.20%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e65.00%\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e*For differentiating MS from MR, a value less than the cut-off for LAstrainSR and values greater than (less negative) the cut-offs for LAstrainCT and LAstrainCD suggest MS.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eBased on our study, left atrial (LA) strain analysis provides valuable insights into the distinct pathophysiological mechanisms underlying mitral stenosis (MS) and mitral regurgitation (MR). The superior diagnostic accuracy of LA conduit strain (LAstrainCD) in differentiating MS from MR (81.8%) underscores the divergent atrial remodeling processes in these conditions, reflecting how the LA adapts differently to pressure overload in MS versus volume overload in MR. The finding that LAstrainCT best assesses MR severity (61.5% accuracy) sheds light on how progressive LA dysfunction occurs as the atrial myocardium struggles to compensate for increasing regurgitant volume. These observations advance our understanding of the unique hemodynamic stresses imposed by MS and MR, and how these stresses lead to specific patterns of LA deformation and functional impairment. By elucidating these differential effects on LA strain, our research contributes to a more comprehensive understanding of the pathophysiology of mitral valve diseases.\\u003c/p\\u003e \\u003cp\\u003eBuilding upon this, our findings align with the established understanding of LA dysfunction in MS and MR. Prior research consistently reveals impaired global LA strain in MS patients compared to healthy controls, with severe cases exhibiting average values around 13.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.75% (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e), and some recent studies reporting even lower peak atrial longitudinal strain (PALS) measurements, averaging approximately 8.2% (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e). In contrast, MR patients generally show a less pronounced reduction in global LA strain, with PALS averaging around 15.2% (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e). While global strain differences offer some discriminatory power, more nuanced variations emerge when analyzing specific strain components and strain rate parameters, as demonstrated by Alves et al(\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e). Notably, Alves et al. specifically compared LA strain parameters in MS and MR patients, finding that systolic and early diastolic strain rates were better preserved in MR, while late diastolic strain rate was more impaired, highlighting the differential impact of these conditions on LA function.\\u003c/p\\u003e \\u003cp\\u003eThis study reveals distinct LA strain patterns in mitral stenosis (MS) and mitral regurgitation (MR), highlighting their value in characterizing the pathophysiological impact of each condition on atrial function. While LA reservoir strain (LAstrainSR) decreases with increasing severity in both MS and MR, LA conduit (LAstrainCD) and contraction strain (LAstrainCT) exhibit less negative values as severity increases. Also, LAstrainCT shows modest value in differentiating the severity of MR (AUC\\u0026thinsp;=\\u0026thinsp;0.650). These findings underscore the potential of LA strain analysis to provide insights into differential atrial remodeling in MS and MR, informing improved diagnostic and therapeutic strategies. However, to the best of our knowledge, no prior study has specifically focused on elaborating the distinct pathophysiology of LA remodeling in MS and MR in a comparative manner using LA strain parameters. Our study uniquely addresses this gap by demonstrating how LA strain parameters can be utilized to understand and differentiate the distinct atrial remodeling processes driven by pressure overload in MS and volume overload in MR.\\u003c/p\\u003e \\u003cp\\u003eBuilding upon the diagnostic utility of LA strain analysis and its ability to differentiate between MS and MR, it's crucial to consider the clinical value of these measurements in the broader context of mitral valve disease management. Left atrial strain measurements have emerged as important prognostic indicators, offering insights beyond conventional parameters like LA volume. In patients with mitral regurgitation, peak atrial longitudinal strain (PALS) has proven particularly valuable, identifying left atrial dysfunction even in asymptomatic patients and correlating with atrial fibrosis, remodeling, and long-term survival after valve surgery (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e). PALS measurements serve as significant predictors of atrial fibrillation development and cardiovascular outcomes in patients with mitral valve disease (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). In fact, studies have demonstrated that reduced PALS values are strongly associated with the onset of atrial fibrillation, as impaired reservoir function reflects underlying structural remodeling and fibrosis within the left atrium(\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e). Furthermore, preoperative LA strain imaging provides valuable information for predicting outcomes after surgical interventions, including the degree of LA fibrosis and remodeling after mitral valve replacement(\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e). Finally, assessing LA strain parameters before and after interventions like PTMC and MVR in patients with mitral stenosis can help guide decision-making regarding timing and type of intervention, as well as predict the likelihood of maintaining sinus rhythm post-procedure (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). While our study focuses on the differential diagnostic capabilities of specific LA strain parameters in MS and MR, the existing literature underscores the broader clinical utility of LA strain as a prognostic marker and a tool for guiding treatment strategies in patients with mitral valve disease.\\u003c/p\\u003e \\u003cp\\u003eWhile our findings demonstrate the potential of LAstrainCD in differentiating MS from MR and LAstrain CT in assessing MR severity, it's essential to acknowledge the limitations that affect the generalizability of our results. The study population, while carefully selected based on specific inclusion and exclusion criteria, may not fully represent the broader spectrum of patients with mitral valve disease. For instance, the exclusion of patients with significant co-morbidities like severe coronary artery disease, other significant valvular lesions, or advanced heart failure, limits the applicability of our findings to patients with relatively isolated MS or MR. Additionally, the single-center design and relatively modest sample size may introduce selection bias and limit the statistical power to detect more subtle differences in LA strain parameters. Further research involving larger, multi-center cohorts with more diverse patient populations is needed to validate these findings and establish the clinical utility of LAstrainCD and LAstrainCT in routine clinical practice.\\u003c/p\\u003e \\u003cp\\u003eFuture research should focus on addressing the limitations of the current study and expanding our understanding of LA strain in mitral valve disease. Specifically, investigations incorporating patients with a wider range of co-morbidities and disease severity are warranted. Furthermore, longitudinal studies assessing the prognostic value of LAstrainCD and LAstrainCT in predicting clinical outcomes, such as atrial fibrillation, heart failure hospitalization, and mortality, would provide valuable insights into the long-term clinical implications of LA dysfunction in MS and MR. Finally, exploring the incremental value of LA strain analysis in combination with other established echocardiographic parameters and biomarkers could further refine risk stratification and guide personalized treatment strategies for patients with mitral valve disease. Investigating the impact of different treatment strategies (e.g., medical management, percutaneous interventions, surgical repair/replacement) on LA strain parameters and clinical outcomes would also be of significant clinical relevance. Further research needed to use AI based analysis to improve diagnostic value of LA strain in such conditions\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eLA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eLeft Atrium/Left Atrial\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eMS\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eMitral Stenosis\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eMR\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eMitral Regurgitation\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eLVEF\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eLeft Ventricular Ejection Fraction\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eASE\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eAmerican Society of Echocardiography\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eEACVI\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eEuropean Association of Cardiovascular Imaging\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eEROA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eEffective Regurgitant Orifice Area\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eRV\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eRegurgitant Volume\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eMVA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eMitral Valve Area\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eTTE\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eTransthoracic Echocardiography\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eLAstrainSR\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eLA reservoir strain\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eLAstrainCD\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eConduit phase strain\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eLAstrainCT\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eContraction phase strain\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003epLASRr\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003epeak atrial longitudinal strain rate (positive, reservoir)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003epLASRcd\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003epeak atrial longitudinal strain rate (negative, conduit)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003epLASRct\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003epeak atrial longitudinal strain rate (negative, contraction)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eLAVi\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eLeft Atrial Volume Index\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003ePACS\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003ePeak atrial contraction strain\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003ePALS\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003ePeak atrial longitudinal strain\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eSPSS\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eStatistical Package for the Social Sciences\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eANOVA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eanalysis of variance\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eROC\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eReceiver Operating Characteristic\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eEthics Approval and Consent to Participate\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was reviewed and approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran (Approval Number: IRSBMU.RETECH.REC.1403.316). Written informed consent was obtained from all participants prior to their inclusion in the study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\\u003c/p\\u003e\\n\\u003cp\\u003eConsent for Publication\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable (as no individual patient data is presented).\\u003c/p\\u003e\\n\\u003cp\\u003eAvailability of Data and Materials\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003eCompeting Interests\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no conflicts of interest.\\u003c/p\\u003e\\n\\u003cp\\u003eFunding\\u003c/p\\u003e\\n\\u003cp\\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\\u003c/p\\u003e\\n\\u003cp\\u003eAuthors\\u0026apos; Contributions\\u003c/p\\u003e\\n\\u003cp\\u003eFariba Bayat: Data collection, manuscript writing.\\u003c/p\\u003e\\n\\u003cp\\u003eSepideh Jame Bozorgi: Data collection, manuscript writing and analysis.\\u003c/p\\u003e\\n\\u003cp\\u003eMohammad Khani: Conceptualization, methodology, and supervision.\\u003c/p\\u003e\\n\\u003cp\\u003eNahid Mohebi Saeen: Conceptualization, methodology, supervision, and manuscript editing.\\u003c/p\\u003e\\n\\u003cp\\u003eAcknowledgments\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eLupu D, Nedelcu L, Ț\\u0026icirc;nț D. The Interplay between Severe Cirrhosis and Heart: A Focus on Diastolic Dysfunction. Journal of Clinical Medicine. 2024;13.\\u003c/li\\u003e\\n\\u003cli\\u003ePanesar D, Burch M. Assessment of Diastolic Function in Congenital Heart Disease. Frontiers in Cardiovascular Medicine. 2017;4.\\u003c/li\\u003e\\n\\u003cli\\u003eHalley CM, Houghtaling PL, Khalil MK, Thomas JD, Jaber WA. Mortality rate in patients with diastolic dysfunction and normal systolic function. Archives of internal medicine. 2011;171 12:1082-7.\\u003c/li\\u003e\\n\\u003cli\\u003eFletcher AJ, Lapidaire W, Leeson P. Machine Learning Augmented Echocardiography for Diastolic Function Assessment. Frontiers in Cardiovascular Medicine. 2021;8.\\u003c/li\\u003e\\n\\u003cli\\u003eFrikha Z, Girerd N, Huttin O, Courand P-Y, Bozec E, Olivier A, et al. Reproducibility in Echocardiographic Assessment of Diastolic Function in a Population Based Study (The STANISLAS Cohort Study). PLoS ONE. 2015;10.\\u003c/li\\u003e\\n\\u003cli\\u003eSamiei N, Abbasi F, Shojaeifard M, Parsaee M, Hosseini S, Rezaei Y, Naderi N. The Role of Left Atrial Strain in Detecting Left Ventricular Diastolic Dysfunction: Comparison between the 2009 and 2016 Recommendations. The Journal of Tehran University Heart Center. 2021;16:58 - 67.\\u003c/li\\u003e\\n\\u003cli\\u003eBarberato SH, Romano M, Beck ALdS, Rodrigues ACT, Almeida ALC, Assun\\u0026ccedil;\\u0026atilde;o BMBL, et al. Position Statement on Indications of Echocardiography in Adults - 2019. Arquivos Brasileiros de Cardiologia. 2019;113:135 - 81.\\u003c/li\\u003e\\n\\u003cli\\u003eNagueh SF, Smiseth OA, Appleton CP, Byrd BF, Dokainish HM, Edvardsen T, et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. European heart journal cardiovascular Imaging. 2016;17 12:1321-60.\\u003c/li\\u003e\\n\\u003cli\\u003eCameli M, Lisi M, Giacomin E, Caputo M, Navarri R, Malandrino A, et al. Chronic mitral regurgitation: left atrial deformation analysis by two-dimensional speckle tracking echocardiography. Echocardiography. 2011;28(3):327-34.\\u003c/li\\u003e\\n\\u003cli\\u003eRobinson S, Ring LS, Augustine DX, Rekhraj S, Oxborough DL, Harkness A, et al. The assessment of mitral valve disease: a guideline from the British Society of Echocardiography. Echo Research and Practice. 2021;8:G87 - G136.\\u003c/li\\u003e\\n\\u003cli\\u003eMangia M, D\\u0026rsquo;Andrea E, Cecchetto A, Beccari R, Mele D, Nistri S. Current and Clinically Relevant Echocardiographic Parameters to Analyze Left Atrial Function. Journal of Cardiovascular Development and Disease. 2024;11.\\u003c/li\\u003e\\n\\u003cli\\u003eKreimer F, Gotzmann M. Left Atrial Cardiomyopathy \\u0026ndash; A Challenging Diagnosis. Frontiers in Cardiovascular Medicine. 2022;9.\\u003c/li\\u003e\\n\\u003cli\\u003eCaso P, Ancona R, Salvo Gd, Pinto SC, Macrino M, Palma VD, et al. Atrial reservoir function by strain rate imaging in asymptomatic mitral stenosis: prognostic value at 3 year follow-up. European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology. 2009;10 6:753-9.\\u003c/li\\u003e\\n\\u003cli\\u003eUsuku H, Yamamoto E, Higashi R, Nozuhara A, Shirahama Y, Oike F, et al. Prognostic value of left atrial stiffness in patients undergoing transcatheter aortic valve implantation. International Journal of Cardiology Heart \\u0026amp; Vasculature. 2024;56.\\u003c/li\\u003e\\n\\u003cli\\u003eSravan K Reddy N, Ranjan Shetty K, Sudhakar Rao M, Sree Madhurya Reddy M. Strain imaging to assess early effects of successful percutaneous balloon mitral valvotomy on left atrium mechanics. The Egyptian Heart Journal. 2019;71.\\u003c/li\\u003e\\n\\u003cli\\u003eRyanti D, Ketaren AP, Mukhtar Z, Akbar NZ, Lubis AC, Ardini TW. Correlation between Peak Left Atrial Longitudinal Strain and The Severity of Mitral Valve Disease at Haji Adam Malik General Hospital Medan. Indonesian Journal of Cardiology. 2024.\\u003c/li\\u003e\\n\\u003cli\\u003eAlves PC, Marinho AV, Ferreira J, Milner J, Freitas AA, Ferreira C, et al. P320 Left atrial mechanics in moderate mitral valve disease: earlier markers of damage. European Journal of Echocardiography. 2020;21.\\u003c/li\\u003e\\n\\u003cli\\u003eCameli M. Echocardiography strain: why is it used more and more? European Heart Journal Supplements : Journal of the European Society of Cardiology. 2022;24:I38 - I42.\\u003c/li\\u003e\\n\\u003cli\\u003eRohani A, Kargar S, Fazlinejad A, Ghaderi F, Vakili V, Falsoleiman H, Bagheri R. Acute Effect of Treatment of Mitral Stenosis on Left Atrium Function. Annals of Cardiac Anaesthesia. 2017;20:42 - 4.\\u003c/li\\u003e\\n\\u003cli\\u003eDi Salvo G, Caso P, Lo Piccolo R, Fusco A, Martiniello AR, Russo MG, et al. Atrial Myocardial Deformation Properties Predict Maintenance of Sinus Rhythm After External Cardioversion of Recent-Onset Lone Atrial Fibrillation: A Color Doppler Myocardial Imaging and Transthoracic and Transesophageal Echocardiographic Study. Circulation. 2005;112:387-95.\\u003c/li\\u003e\\n\\u003cli\\u003ePastore MC, Mandoli GE, Dokollari A, Bisleri G, D\\u0026rsquo;Ascenzi F, Santoro C, et al. Speckle tracking echocardiography in primary mitral regurgitation: should we reconsider the time for intervention? Heart Failure Reviews. 2021;27:1247 - 60.\\u003c/li\\u003e\\n\\u003cli\\u003eMalik V, Subramaniam A, Kapoor PM. Strain and strain rate: An emerging technology in the perioperative period. Annals of Cardiac Anaesthesia. 2016;19:112 - 21.\\u003c/li\\u003e\\n\\u003cli\\u003eHer A-Y, Choi E-Y, Shim CY, Song BW, Lee S, Ha J-W, et al. Prediction of Left Atrial Fibrosis With Speckle Tracking Echocardiography in Mitral Valve Disease: A Comparative Study With Histopathology. Korean Circulation Journal. 2012;42:311 - 8.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-cardiovascular-disorders\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bcar\",\"sideBox\":\"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bcar/default.aspx\",\"title\":\"BMC Cardiovascular Disorders\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Left Atrial Strain, Mitral Valve Disease Pathophysiology, Mitral Regurgitation, Mitral Stenosis, Atrial Remodeling\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6408954/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6408954/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eLeft atrial (LA) strain analysis is an emerging echocardiographic technique for assessing LA function. This study aimed to compare LA strain parameters in patients with mitral stenosis (MS) and mitral regurgitation (MR) to identify discriminators between these conditions.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eThis cross-sectional study included 44 patients with moderate-to-severe MR and 44 patients with severe-to-very severe MS, all with normal left ventricular ejection fraction. Patients with left ventricular systolic dysfunction, ischemic mitral regurgitation, or atrial fibrillation were excluded. Clinical data were collected, and LA strain analysis was performed offline using EchoPAC software. The study analyzed LA reservoir, conduit, and contractile strain components.LAstrainSR, LAstrainCD and LAstrainCT were derived and analyzed for their diagnostic performance. Data were analyzed using SPSS version 26.0, with one-way ANOVA used to compare LA strain parameters between groups.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eLAstrainCD demonstrated the highest diagnostic accuracy (81.8%) for differentiating MS from MR, making it the most reliable strain parameter. LAstrainCT showed the best performance for assessing MR severity, with a moderate accuracy of 61.5%.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003ethis study elucidates the distinct impacts of mitral stenosis and regurgitation on left atrial function, as reflected by LA strain parameters. LAstrainCD emerges as a key discriminator between these conditions, highlighting differences in atrial remodeling due to pressure versus volume overload. Furthermore, LAstrainCT's correlation with MR severity enhances our understanding of atrial adaptation to regurgitant volume. These findings advance the knowledge of mitral valve disease pathophysiology, providing a foundation for improved diagnostic and therapeutic strategies.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Left Atrial Strain in Mitral Valve Disease: A Comparative Analysis of Regurgitation and Stenosis\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-05-08 14:47:15\",\"doi\":\"10.21203/rs.3.rs-6408954/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-08-20T08:23:46+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-08-14T16:13:17+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"280334020781398734157364388850025481970\",\"date\":\"2025-07-29T12:16:16+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"36932624903222572208617940038378042438\",\"date\":\"2025-07-28T19:03:10+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"182347285848026835080312147055219596172\",\"date\":\"2025-07-24T21:25:52+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"50681398732134378768106267333774797975\",\"date\":\"2025-07-24T17:53:19+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"191435928186678922583884622257163394282\",\"date\":\"2025-05-14T06:32:18+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"36814858347860069111488792855455004838\",\"date\":\"2025-05-11T21:06:36+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-05-08T15:06:54+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"109981280999693378616903775776725369821\",\"date\":\"2025-05-01T06:02:33+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-05-01T03:51:04+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-04-25T03:45:37+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-04-21T17:20:02+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-04-18T13:36:49+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Cardiovascular Disorders\",\"date\":\"2025-04-18T13:35:39+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-cardiovascular-disorders\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bcar\",\"sideBox\":\"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bcar/default.aspx\",\"title\":\"BMC Cardiovascular Disorders\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"8615a248-6ee2-4251-a3c2-f854f07c5dea\",\"owner\":[],\"postedDate\":\"May 8th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-02-02T16:05:52+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-6408954\",\"link\":\"https://doi.org/10.1186/s12872-025-05427-8\",\"journal\":{\"identity\":\"bmc-cardiovascular-disorders\",\"isVorOnly\":false,\"title\":\"BMC Cardiovascular Disorders\"},\"publishedOn\":\"2026-01-26 15:59:25\",\"publishedOnDateReadable\":\"January 26th, 2026\"},\"versionCreatedAt\":\"2025-05-08 14:47:15\",\"video\":\"\",\"vorDoi\":\"10.1186/s12872-025-05427-8\",\"vorDoiUrl\":\"https://doi.org/10.1186/s12872-025-05427-8\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6408954\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6408954\",\"identity\":\"rs-6408954\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}