Progression of Hypertrophy and Myocardial Fibrosis in Aortic Stenosis: A Multicenter Cardiac Magnetic Resonance Study

Russell J Everett, Lionel Tastet, Marie-Annick Clavel, Calvin WL Chin, Romain Capoulade, Vassilios S Vassiliou, Jacek Kwiecinski, Miquel Gomez, Edwin JR van Beek, Audrey C White, Sanjay K Prasad, Eric Larose, Christopher Tuck, Scott Semple, David E Newby, Philippe Pibarot, Marc R Dweck

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Abstract

Background: Aortic stenosis is accompanied by progressive left ventricular hypertrophy and fibrosis. We investigated the natural history of these processes in asymptomatic patients and their potential reversal post-aortic valve replacement (AVR). 
Methods: Asymptomatic and symptomatic patients with aortic stenosis underwent repeat echocardiography and magnetic resonance imaging. Changes in peak aortic-jet velocity, left ventricular mass index, diffuse fibrosis (indexed extracellular volume), and replacement fibrosis (late gadolinium enhancement [LGE]) were quantified. 
RESULTS: In 61 asymptomatic patients (43% mild, 34% moderate, and 23% severe aortic stenosis), significant increases in peak aortic-jet velocity, left ventricular mass index, indexed extracellular volume, and LGE mass were observed after 2.1±0.7 years, with the most rapid progression observed in patients with most severe stenosis. Patients with baseline midwall LGE (n=16 [26%]; LGE mass, 2.5 g [0.8–4.8 g]) demonstrated particularly rapid increases in scar burden (78% [50%–158%] increase in LGE mass per year). In 38 symptomatic patients (age, 66±8 years; 76% men) who underwent AVR, there was a 19% (11%–25%) reduction in left ventricular mass index (P<0.0001) and an 11% (4%–16%) reduction in indexed extracellular volume (P=0.003) 0.9±0.3 years after surgery. By contrast midwall LGE (n=10 [26%]; mass, 3.3 g [2.6–8.0 g]) did not change post-AVR (n=10; 3.5 g [2.1–8.0 g]; P=0.23), with no evidence of regression even out to 2 years. 
Conclusions: In patients with aortic stenosis, cellular hypertrophy and diffuse fibrosis progress in a rapid and balanced manner but are reversible after AVR. Once established, midwall LGE also accumulates rapidly but is irreversible post valve replacement. Given its adverse long-term prognosis, prompt AVR when midwall LGE is first identified may improve clinical outcomes.
Original languageEnglish
Article numbere007451
JournalCirculation: Cardiovascular Imaging
Volume11
Issue number6
Early online date18 Jun 2018
DOIs
Publication statusPublished - Jun 2018

Keywords

  • aortic valve stenosis
  • magnetic resonance imaging
  • myocardial fibrosis
  • valve replacement

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