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This clinical follow-up study investigated predictors for cardiac death in conservatively and surgical treated patients with moderate and severe AS.Methods: 223 patients (mean age 79±8 years) with either stable moderate AS (n=79) or severe AS (n=157) who refused initially aortic valve replacement (AVR) (no AVR group n=95) were examined. A subgroup of these 157 patients underwent AVR (AVR group n= 62) as they changed their mind for conventional AVR. Routine clinical data was assessed together with conventional echocardiography including the measurement of longitudinal wall function and deformation (mitral ring displacement, strain and strain rate imaging). The mean observation time for survivors was 2.9±0.5 years. All-cause death and cardiac death was observed. Follow-up was 100% complete.Results: During follow-up all cause death in No AVR groups was 14% in moderate AS compared to 60% in severe AS. No Cardiac death was seen in moderate AS compared to 49% in severe AS. Clinical symptoms NYHA class II-IV, valvulo arterial impedance (Zva) and mitral ring displacement < 7mm or strain rate < -1.0 s-1 showed a significant risk for all cause death with a hazard ratio of 3.7 (<7mm) and 4.3 (<-1.0s-1). In contrast Ejection Fraction (EF) or Euro-Score were not able to predict risk for cardiac or all cause death. Further more in multivariable analysis, only longitudinal mitral ring displacement and longitudinal strain rate retained in regression analysis.Summary: These data show that prognosis in patients with AS is determined by symptoms, hemodynamics and cardiac function. A more comprehensive assessment of cardiac function is essential. Determining longitudinal mitral ring displacement is feasible parameter with a high sensitivity and reproducibility indicating patients risk.