Dataset Information

Differences in Aortic Valve and Left Ventricular Parameters Related to the Severity of Myocardial Fibrosis in Patients with Severe Aortic Valve Stenosis.

ABSTRACT:

Objective

This study investigated the morphological and functional characteristics of the aortic valve and the left ventricular (LV) systolic functional parameters and myocardial mass related to the severity of myocardial fibrosis (MF) in patients with severe aortic valve stenosis (AS).

Materials and methods

We retrospectively enrolled 81 patients (48 men; mean age: 59±12 years) with severe AS who underwent transthoracic echocardiography (TTE), cardiac computed tomography (CCT), and cardiovascular magnetic resonance (CMR) within 1 month and subsequent aortic valve surgery. Degree of MF was determined on delayed contrast-enhanced CMR with visual sub-segmental analysis-based quantification and was classified into three groups (no, mild, and severe) for identifying the differences in LV function and characteristics of the aortic valve. One-way ANOVA, Chi-square test or Fisher's exact test were used to compare variables of the three groups. Univariate multinomial logistic regression analysis was performed to determine the association between the severity of MF and variables on imaging modalities.

Results

Of 81 patients, 34 (42%) had MF (mild, n = 18; severe, n = 16). Aortic valve calcium volume score on CCT, aortic valve area, LV mass index, LV end-diastolic volume index on CMR, presence of mild aortic regurgitation (AR), transaortic mean pressure gradient, and peak velocity on TTE were significantly different among the three groups and were associated with severity of MF on a univariate multinomial logistic regression analysis. Aortic valve calcium grade was different (p = 0.008) among the three groups but not associated with severity of MF (p = 0.375).

Conclusions

A multi-imaging approach shows that severe AS with MF is significantly associated with more severe calcific AS, higher LV end-diastolic volume, higher LV mass, and higher prevalence of mild AR.

SUBMITTER: Song I

PROVIDER: S-EPMC5271376 | biostudies-literature | 2017

REPOSITORIES: biostudies-literature

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Publications

Differences in Aortic Valve and Left Ventricular Parameters Related to the Severity of Myocardial Fibrosis in Patients with Severe Aortic Valve Stenosis.

Song Inyoung I Ko Sung Min SM Yi Jeong Geun JG Chee Hyun Keun HK Kim Jun Seok JS

PloS one 20170127 1

<h4>Objective</h4>This study investigated the morphological and functional characteristics of the aortic valve and the left ventricular (LV) systolic functional parameters and myocardial mass related to the severity of myocardial fibrosis (MF) in patients with severe aortic valve stenosis (AS).<h4>Materials and methods</h4>We retrospectively enrolled 81 patients (48 men; mean age: 59±12 years) with severe AS who underwent transthoracic echocardiography (TTE), cardiac computed tomography (CCT), a ...[more]

PMID: 28129367

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Project description:BACKGROUND:Myocardial fibrosis occurs in aortic stenosis (AS) as part of the hypertrophic response. It can be detected by LGE, which is associated with an adverse prognosis in the form of increased mortality and morbidity. OBJECTIVES:To assess the prevalence of LGE patterns using cardiac magnetic resonance (CMR) in severe AS patients and to study its prognostic significance. METHODS:Patients enrolled into the study from June 2012 to November 2014. All the patients underwent CMR and various patterns of LGE studied. These patients if symptomatic were advised AVR and others were managed conservatively. All patients were followed up and watched for outcomes like mortality, heart failure/hospitalization for cardiovascular cause, fall in left ventricular ejection fraction (LVEF) ?20% and arrhythmia. RESULTS:A total of 109 patients (mean age-57.7±12.5yrs) underwent CMR with 63 males. These patients were followed up for a mean of 13 months. Among 38 patients who underwent AVR, 6 died (5-cardiovascular cause, 1-non cardiovascular). 71 patients were managed conservatively out of which 18 died (17-cardiovascular cause, 1-non cardiovascular cause). LGE patterns were seen in 46 patients (43%); mid myocardial enhancement was seen in 31.1% of cases (33 patients). No LGE pattern was seen in 57%(63 patients). Basal and mid regions were maximally involved with mid myocardial enhancement in 66% & 68.3% respectively. LV ejection fraction (p=0.002), peak aortic systolic velocity (p=0.01) and peak aortic systolic gradient (p=0.02) were the main predictors of LGE. Main predictors of primary outcome were NYHA class [OR- 13.4(2.8-26.1), p?0.001], age- 62±?9.6yrs(p=0.001), EF simpson-50.9±13%(p??0.001), LGE[OR 2.8 (1.27-6.47),p=0.01], number of segments involved [2.37±2.1,P?0.001] & CMR LV mass (151.73±32gms, p=0.007). LGE predicted heart failure/hospitalization for cardiovascular cause [OR- 3.8(1.2-11.9), p=0.01] and fall in LVEF [OR- 5.8(1.5-22.5), p=0.005]. Patients with LGE had 2.87 times risk of adverse outcomes and patients with more than 3 segment LGE involvement had again increased chances for adverse outcomes. CONCLUSIONS:LGE was detected by CMR in 43% of patients with severe AS. It predicted recurrent heart failure, hospitalization for cardiovascular cause and fall in LV ejection fraction. Our study has laid a path to larger prospective studies with long term follow up to assess the prognostic impact of CMR in patients with severe AS.

Project description:Importance:Clinical practice guidelines currently endorse a reliance on clinical symptoms of overt left ventricular (LV) failure to time aortic valve replacement for severe aortic stenosis; however, delayed aortic valve replacement can result in irreversible LV injury and adverse outcomes. Blood metabolomic signatures possess prognostic value in heart failure; this study assesses whether they are informative in aortic stenosis. Objective:To evaluate the value of metabolomic signatures in reflecting the extent of maladaptive LV remodeling in patients with end-stage aortic stenosis undergoing transcatheter aortic valve replacement, and to assess whether this procedure reverses metabolomic aberrations. Design, Setting, and Participants:This study of 44 patients with symptomatic severe aortic stenosis who underwent transfemoral transcatheter aortic valve replacement at a single-center tertiary care hospital. Liquid chromatography-mass spectrometry-based metabolomic profiling was performed on blood samples collected before and 24 hours after the procedure, and analyses were conducted to identify metabolites related to the measures of LV remodeling. Main Outcomes and Measures:We evaluated LV ejection fraction, LV mass index, and relative wall thickness, as well as levels of the acylcarnitines C16, C18:1, C18:2, C18, C26, choline, and kynurenine. Results:We enrolled 44 patients with severe aortic stenosis with a mean (SD) age of 81.9 (8.5) years, of whom 23 (52%) were women. The mean (SD) LV ejection fraction was 56.7% (18.2%), mean (SD) LV mass index was 117.3 (41.4) g/m2, and relative wall thickness was 0.53 (0.14). The mean β values of acylcarnitines C16, C18:1, C18:2, C18, and C26 were independently associated with LV mass index (C16: mean, 19.24; 95% CI, 5.48-33.01; P = .008; C18:1: mean, 26.18; 95% CI, 14.04-38.32; P < 1.0 × 10-4; C18:2: mean, 17.42; 95% CI, 3.40-31.43; P = .02; C18: mean, 25.25; 95% CI, 10.91-39.58; P = .001; C26: mean, 19.93; 95% CI, 4.41-35.45; P = .01), even after adjustments for age, sex, diabetes status, renal function, and B-type natriuretic peptide (BNP). Circulating levels of C18:2 acylcarnitine were associated with LV ejection fraction before and after multivariable adjustment (mean, -6.11; 95% CI, -10.88 to 1.34; P = .01). Blood metabolite levels did not independently relate to relative wall thickness. Within 24 hours of transcatheter aortic valve replacement, circulating levels of C16 decreased by 30.2% (P = 7.3 × 10-6), C18:1 by 42.7% (P = 3.7 × 10-8), C18:2 by 37.3% (P = 5.1 × 10-6), and C18 by 38.3% (P = 3.4 × 10-5). Conclusions and Relevance:In symptomatic patients with severe aortic stenosis undergoing transcatheter aortic valve replacement, circulating levels of long-chain acylcarnitines were independently associated with measures of maladaptive LV remodeling, and metabolic perturbations lessened after procedure completion. Further efforts are needed to determine the clinical applicability of these novel biomarkers.

Project description:ImportanceDiagnosis of low-gradient severe aortic stenosis (AS) is challenging. We hypothesized that the time between left ventricular (LV) and aortic systolic pressure peaks (TLV-Ao) is associated with aortic stenosis (AS) severity and may have additive value in diagnosing severe AS, especially in patients with low-gradient AS.ObjectiveTo investigate the diagnostic utility of measuring catheter-based TLV-Ao in patients with severe AS.Design, setting, and participantsWe studied 123 patients with severe AS at the Cleveland Clinic Foundation, a tertiary referral center, who underwent transcatheter aortic valve replacement (TAVR) via femoral access and had pre-TAVR cardiac computed tomography assessment and hemodynamic measurements recorded during a TAVR procedure. All patients received hemodynamic evaluation, echocardiographic assessment, and quantification of aortic valve calcification (AVC) by multidetector computed tomography. Hemodynamic data were collected via left heart catheterization done just before TAVR, and TLV-Ao was calculated offline. Data were analyzed between October 5, 2015, and July 20, 2016.Main outcomes and measuresThe association between TLV-Ao and AVC or other conventional imaging parameters was analyzed.ResultsOf the included patients, the mean (SD) age was 81 (9) years, and 65 (54%) were men (54%). Among 123 patients, 48 patients (39%) had low-gradient AS (<40 mm Hg) and mean (SD) TLV-Ao was 69 (39) milliseconds. In multivariable logistic regression analyses, higher TLV-Ao (odds ratio [OR], 1.02; 95% CI, 1.01-1.04; P = .002) and higher peak aortic valve (AV) velocity (OR, 1.01; 95% CI, 1.00-1.02; P = .008) were independently associated with severe AVC (AVC >1000 AU). Adding TLV-Ao to the peak AV velocity and AV area showed significant incremental value to be associated with AVC, with a net reclassification improvement of 0.61 (95% CI, 0.23-0.99; P = .002) and integrated discriminatory improvement of 0.09 (95% CI, 0.03-0.16; P = .003). In a subgroup of patients with low-grade AS, higher TLV-Ao was the only parameter associated with severe AVC (OR, 1.02; 95% CI, 1.001-1.04; P = .03).Conclusions and relevanceProlonged TLV-Ao was associated with severe AVC. This catheter-based hemodynamic index may be an additional surrogate to differentiate low-gradient true severe AS. Larger, prospective studies investigating the role of TLV-Ao as a marker of clinical outcomes in patients undergoing TAVR are required.

Dataset Information

Differences in Aortic Valve and Left Ventricular Parameters Related to the Severity of Myocardial Fibrosis in Patients with Severe Aortic Valve Stenosis.

Objective

Materials and methods

Results

Conclusions

Publications

Differences in Aortic Valve and Left Ventricular Parameters Related to the Severity of Myocardial Fibrosis in Patients with Severe Aortic Valve Stenosis.

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