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Purpose: To evaluate changes in multidirectional strain between symptomatic and asymptomatic chronic aortic regurgitation (AR) patients with preserved left ventricular (LV) ejection fraction (EF) using two-dimensional speckle-tracking strain imaging (2D-STI). The role of baseline myocardial strain to predict the development of indication for surgery in asymptomatic patients was also evaluated.Methods: A total of 129 patient (age 55±17 years, 64% male) with moderate or severe AR and EF>50% was included. Sixty-one (47%) patients had symptoms at baseline. Of the 68 asymptomatic patients, 50 patients were follow-up conservatively for development of symptom/EF≤50% (indication for surgery). Standard echocardiography and 2D-STI were performed at baseline.Results: Symptomatic AR patients exhibited larger LV end-diastolic volume index (95±33 vs. 83±27 mL/m2, p=0.03), vena contracta width (6.2±1.1 vs. 5.5±1.0 mm, p<0.01) and jet to LV outflow tract width ratio (58±11 vs. 50±10%, p<0.01) than asymptomatic patients. Moreover, more significant impairment in longitudinal (-14.9±3.0 vs. 16.8±2.5%, p<0.01), circumferential (-17.5±2.9 vs. -19.3±2.8%, p<0.01) and radial strains (35.7±12.2 vs. 43.1±14.7%, p<0.01) were observed in symptomatic patients at baseline. Among asymptomatic patients who were follow-up for a period of 3.5±2.4 years, 26 (52%) patients developed indication for surgery. Comparing patients with and without indication for surgery, there were no differences in baseline LV volumes, EF and colour Doppler assessment between the 2 groups. However, longitudinal (-15.8±2.0 vs. -17.8±2.9%, p<0.01) and circumferential strains (-18.3±2.4 vs. -20.0±2.9%, p=0.03) were already significantly more reduced in patients who developed indication for surgery. Importantly, impaired baseline longitudinal strain was an independent predictor of future need for surgery after correcting for age, medication use, EF and LV dimension (per 1% decrease, OR=1.52, 95% CI 1.05 – 2.21, p=0.03).Conclusions: LV strains were significantly more reduced in symptomatic than asymptomatic patients AR patients despite normal EF. In asymptomatic AR patients, longitudinal strain, as assessed with 2D-STI, could identify patients who would require valve surgery later.