Short-term adverse remodeling progression in asymptomatic aortic stenosis
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Short-term adverse remodeling progression in asymptomatic aortic stenosis Anvesha Singh 1 & Daniel C. S. Chan 1 & Prathap Kanagala 1,2 & Kai Hogrefe 3 & Damian J. Kelly 4 & Jeffery P. Khoo 5 & David Sprigings 6 & John P. Greenwood 7 & Ahmed M. S. E. K. Abdelaty 1,8 & Michael Jerosch-Herold 9 & Leong L. Ng 1 & Gerry P. McCann 1 Received: 17 July 2020 / Revised: 7 September 2020 / Accepted: 3 November 2020 # The Author(s) 2020
Abstract Objectives Aortic stenosis (AS) is characterised by a long and variable asymptomatic course. Our objective was to use cardiovascular magnetic resonance imaging (MRI) to assess progression of adverse remodeling in asymptomatic AS. Methods Participants from the PRIMID-AS study, a prospective, multi-centre observational study of asymptomatic patients with moderate to severe AS, who remained asymptomatic at 12 months, were invited to undergo a repeat cardiac MRI. Results Forty-three participants with moderate-severe AS (mean age 64.4 ± 14.8 years, 83.4% male, aortic valve area index 0.54 ± 0.15 cm2/m2) were included. There was small but significant increase in indexed left ventricular (LV) (90.7 ± 22.0 to 94.5 ± 23.1 ml/m2, p = 0.007) and left atrial volumes (52.9 ± 11.3 to 58.6 ± 13.6 ml/m2, p < 0.001), with a decrease in systolic (LV ejection fraction 57.9 ± 4.6 to 55.6 ± 4.1%, p = 0.001) and diastolic (longitudinal diastolic strain rate 1.06 ± 0.2 to 0.99 ± 0.2 1/s, p = 0.026) function, but no overall change in LV mass or mass/volume. Late gadolinium enhancement increased (2.02 to 4.26 g, p < 0.001) but markers of diffuse interstitial fibrosis did not change significantly (extracellular volume index 12.9 [11.4, 17.0] ml/ m2 to 13.3 [11.1, 15.1] ml/m2, p = 0.689). There was also a significant increase in the levels of NT-proBNP (43.6 [13.45, 137.08] pg/ml to 53.4 [19.14, 202.20] pg/ml, p = 0.001). Conclusions There is progression in cardiac remodeling with increasing scar burden even in asymptomatic AS. Given the lack of reversibility of LGE post-AVR and its association with long-term mortality post-AVR, this suggests the potential need for earlier intervention, before the accumulation of LGE, to improve the long-term outcomes in AS. Key Points • Current guidelines recommend waiting until symptom onset before valve replacement in severe AS. • MRI showed clear progression in cardiac remodeling over 12 months in asymptomatic patients with AS, with near doubling in LGE. • This highlights the need for potentially earlier intervention or better risk stratification in AS. Keywords Aortic valve stenosis . Magnetic resonance imaging . Fibrosis
* Anvesha Singh [email protected] 1
Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Groby road, Leicester LE3 9QP, UK
2
Department of Cardiology, Aintree University Hospital, Liverpool, UK
3
Cardiology Department, Kettering General Hospital Foundation Trust, Rothwell Rd, Kettering NN16 8UZ, UK
4
Cardiology Department, Royal Derby Hospital,
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