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Prognostic Signiﬁcance of LGE by CMR in Aortic Stenosis Patients Undergoing Valve Replacement
Gilles Barone-Rochette, MD, Sophie Piérard, MD, Christophe De Meester de Ravenstein, MS, Stéphanie Seldrum, MD, Julie Melchior, MD, Frédéric Maes, MD, Anne-Catherine Pouleur, MD, PHD, David Vancraeynest, MD, PHD, Agnes Pasquet, MD, PHD, Jean-Louis Vanoverschelde, MD, PHD, Bernhard L. Gerber, MD, PHD
BACKGROUND Prior studies have shown that late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) can detect focal ﬁbrosis in aortic stenosis (AS), suggesting that it might predict higher mortality risk.
OBJECTIVES This study was conducted to evaluate whether LGE-CMR can predict post-operative survival in patients with severe AS undergoing aortic valve replacement (AVR).
METHODS We prospectively evaluated survival (all-cause and cardiovascular disease related) according to LGE-CMR status in 154 consecutive AS patients (96 men; mean age: 74 6 years) without a history of myocardial infarction un- dergoing surgical AVR and in 40 AS patients undergoing transcatheter aortic valve replacement (TAVR).
RESULTS LGE was present in 29% of patients undergoing surgical AVR and in 50% undergoing TAVR. During a median follow-up of 2.9 years, 21 patients undergoing surgical AVR and 20 undergoing TAVR died. In surgical AVR, the presence of LGE predicted higher post-operative mortality (odds ratio: 10.9; 95% conﬁdence interval [CI]:
1.2 to 100.0; p ¼ 0.02) and worse all-cause survival (73% vs. 88%; p ¼ 0.02 by log-rank test) and cardiovascular disease related survival (85% vs. 95%; p ¼ 0.03 by log-rank test) on 5-year Kaplan-Meier estimates of survival
after surgical AVR. Multivariate Cox analysis identiﬁed the presence of LGE (hazard ratio: 2.8; 95% CI: 1.3 to 6.9; p ¼ 0.025) and New York Heart Association functional class III/IV (hazard ratio: 3.2; 95% CI: 1.1 to 8.1; p < 0.01) as the sole independent predictors of all-cause mortality after surgical AVR. The presence of LGE also predicted
higher all-cause mortality (p ¼ 0.05) and cardiovascular disease related mortality (p ¼ 0.03) in the subgroup of patients without angiographic coronary artery disease (n ¼ 110) and higher cardiovascular disease related mortality in 25 patients undergoing transfemoral TAVR.
CONCLUSIONS The presence of LGE indicating focal ﬁbrosis or unrecognized infarct by CMR is an independent predictor of mortality in patients with AS undergoing AVR and could provide additional information in the pre-operative evaluation of risk in these patients. (J Am Coll Cardiol 2014;64:144–54) © 2014 by the American College of Cardiology Foundation.
Severe degenerative aortic stenosis (AS) is the most frequent valvular heart disease in indus- trialized countries and its prevalence steadily afterload and ventricular wall stress of this condition stimulate left ventricular hypertrophic remodeling. Such remodeling is frequently associated with devel- ﬁbrosis (2–6), increases with age (1). The increased pressure opment of adverse intramyocardial ...
From the Valvular Heart Disease Clinic, Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium. Grant support was received from the Fondation Nationale de la Recherche Scientiﬁque of the Belgian gov- ernment (FRSM 3.4598.08, FRSM 3.4508.12.f, FRSM 3.4.589.06.f, and FRSM 1.A461.12). Dr. Barone-Rochette was supported by a grant from the French Federation of Cardiology. Drs. Piérard, Seldrum, and Melchior were supported by a fellowship (Aspirant Candidat Specialiste Doctorant) of the Fondation Nationale de la Recherche Scientiﬁque of the Belgian government. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Barone-Rochette and Piérard contributed equally to this work and are joint ﬁrst authors.Manuscript received August 28, 2013; revised manuscript received January 17, 2014, accepted February 26, 2014.