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Background: Mitral stenosis (MS) is a progressive disease in which, after a long period free of symptoms, often the initial manifestation is the onset of atrial fibrillation (AF), that occurs in about 30-40%. Previous study has demonstrated that atrial myocardial deformation properties, assessed by Doppler Strain rate imaging, are abnormal in patients with MS and the degree of this impairment is predictor of adverse events at 3-year follow-up.Aim of the study: To assess systolic left atrial (LA) reservoir function in asymptomatic MS by two-dimensional (2D) strain (S) and strain rate (SR) imaging and its prognostic value in predicting AF at 4-year follow-up.Methods: Seventy-nine asymptomatic patients (pts) with mild to moderate pure rheumatic MS and 60 healthy controls were evaluated by standard echo-Doppler study (mitral valve area, mean gradient, systolic pulmonary pressure, left atrial (LA) width, LA volumes, LA ejection fraction) and by 2D Speckle Tracking. The end-point at 4-year follow-up was the onset of AF.Results: LA width, volumes and systolic pulmonary pressure were significantly increased (p<0.0001) and LA 2D S and SR were significantly impaired in MS pts (p<0.0001). Peak systolic LA myocardial 2D S and SR were significantly correlated with LA volumes (S: p: 0.01; R:-0.43; SR: p: 0.04; R:-0.34), with LA width (S: p:0.08; R:-0.31), with LA EF (S: p=0.0006, R:0.55; SR: p:0.09; R: 0.29), systolic pulmonary pressure (S: p: 0.06; R:-0.35; SR: p: 0.03; R:-0.39). At 4-year follow-up 16 (20%) pts showed AF at standard ECG or 24-h Holter ECG. MS pts who had AF were older than those who did not, without significant differences for LA dimensions, volumes, EF, compliance index. Instead, atrial myocardial systolic 2D S was significantly impaired in pts with events. In multivariate analysis (age, PHT mitral area, LA volume, systolic pulmonary pressure, LA ejection fraction) the best predictor of AF was LA peak systolic S average (P=0.02; coefficient, 0.22; SE, 0.098), with a sensitivity of 89%, specificity of 81%%, area under ROC curve of 0.761 (SE, 0.085; 95% CI, 0.587 to 0.888, P= 0.002) for a cut-off value of 17.4 %.Conclusions: LA 2D S imaging is abnormal in asymptomatic MS and it predicts AF at 4-year follow-up. It could identify pts who will develop AF, allowing us to start the therapy for reversing fibrosis and anticoagulant therapy to prevent thromboembolism.