Abstract
Background
Despite the wealth of data showing the positive effects on cardiac reverse remodelling
in the long-term, the immediate effects of transcatheter aortic valve implantation
(TAVI) on the left ventricle are yet to be comprehensively described using cardiovascular
magnetic resonance imaging. Also, the link between myocardial fibrosis and acute left
ventricular (LV) mass regression is unknown.
Methods
Fifty-seven patients with severe aortic stenosis awaiting TAVI underwent paired cardiovascular
magnetic resonance scans before and early after the procedure (4 [interquartile range,
3-5] days). LV mass, volume, and function were measured. Late gadolinium enhancement
(LGE) imaging was performed to assess for the presence of and pattern of myocardial
fibrosis.
Results
After the procedure, 53 (95%) patients experienced an immediate (10.1 ± 7.1%) reduction
in indexed LV mass (LVMi) from 76 ± 15.5 to 68.4 ± 14.7 g/m2 (P < 0.001). Those with no LGE experienced the greatest LVMi regression (13.9 ± 7.1%)
compared with those with a midwall/focal fibrosis pattern LGE (7.4 ± 5.8%) and infarct
pattern LGE (7.2 ± 7.0%; P = 0.005). There was no overall change in LV ejection fraction (LVEF; 55.1 ± 12.1%
to 55.5 ± 10.9%; P = 0.867), however a significant improvement in LVEF was seen in those with abnormal
(< 55%; n = 24; 42%) baseline LVEF (43.2 ± 8.9 to 46.7 ± 10.5%; P = 0.027). Baseline LVMi (P = 0.005) and myocardial fibrosis (P < 0.001) were strong independent predictors of early LVMi regression.
Conclusions
LV reverse remodelling occurs immediately after TAVI, with significant LV mass regression
in the total population and an improvement in LVEF in those with preexisting LV impairment.
Those without myocardial fibrosis at baseline experience greater LV mass regression
than those with fibrosis.
Résumé
Introduction
Malgré l’abondance des données sur les effets positifs à long terme du remodelage
cardiaque inverse, les effets immédiats de l’implantation valvulaire aortique par
cathéter (IVAC) au ventricule gauche n’ont pas encore été clairement décrits à l’aide
d’examens cardiovasculaires par imagerie par résonnance magnétique (IRM). De plus,
le lien entre la fibrose myocardique et la régression aiguë de la masse ventriculaire
gauche est inconnu.
Méthodes
Cinquante-sept patients présentant une sténose grave de l’aorte en attente d’une IVAC
se sont soumis à un examen cardiovasculaire par résonnance magnétique avant et peu
après l’intervention (4 jours [intervalle interquartile, 3-5]). La masse, le volume
et la fonction du ventricule gauche ont été mesurés. Un examen par IRM avec « rehaussement
tardif » par le gadolinium a été mené pour évaluer la présence et les caractéristiques
de la fibrose myocardique.
Résultats
Après l’intervention, 53 (95 %) patients ont présenté une régression immédiate (10,1
± 7,1 %) de la masse ventriculaire gauche (indice de masse ventriculaire gauche) qui
est passée de 76 ± 15,5 à 68,4 ± 14,7 g/m2 (p < 0,001). Les patients qui ne s’étaient pas soumis à un rehaussement tardif par le
gadolinium ont présenté la plus importante réduction immédiate de la masse ventriculaire
gauche (13,9 ± 7,1 %) comparativement à ceux ayant présenté, à l’examen avec rehaussement
tardif par le gadolinium, des caractéristiques de fibrose à la mi-paroi ou de fibrose
focale (7,4 ± 5,8 %) et des caractéristiques d’infarctus (7,2 ± 7,0 %; p = 0,005). Dans l’ensemble, aucune modification de la fraction d’éjection du ventricule
gauche (FEVG; de 55,1 ± 12,1 % à 55,5 ± 10,9 %; p = 0,867) n’a été notée; toutefois, une importante amélioration de la FEVG a été observée
chez les patients qui, au départ, présentaient une fraction d’éjection anormale du
ventricule gauche (< 55 %; n = 24; 42 %) (de 43,2 ± 8,9 à 46,7 ± 10,5 %; p = 0,027). Au départ, l’indice de masse ventriculaire gauche (p = 0,005) et la fibrose myocardique (p < 0,001) constituaient de solides facteurs de prédiction indépendants d’une réduction
précoce de l’indice de masse ventriculaire gauche.
Conclusions
Le remodelage inverse du ventricule gauche survient immédiatement après l’IVAC et
s’accompagne d’une régression marquée de la masse ventriculaire dans l’ensemble de
la population ainsi que d’une amélioration de la FEVG chez ceux qui avaient des antécédents
d’insuffisance ventriculaire gauche. Ceux qui ne présentaient pas de fibrose myocardique
au départ ont connu une régression plus importante de la masse ventriculaire gauche
que ceux atteints de fibrose.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Canadian Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Cardiac hypertrophy: useful adaptation or pathologic process?.Am J Med. 1980; 69: 576-584
- Sex differences in aortic stenosis and outcome following surgical and transcatheter aortic valve replacement.J Womens Health (Larchmt). 2015; 24: 986-995
- Assessment of valve haemodynamics, reverse ventricular remodelling and myocardial fibrosis following transcatheter aortic valve implantation compared to surgical aortic valve replacement: a cardiovascular magnetic resonance study.Heart. 2013; 99: 1185-1191
- Hemodynamic outcomes of transcatheter aortic valve replacement and medical management in severe, inoperable aortic stenosis: a longitudinal echocardiographic study of cohort b of the PARTNER trial.J Am Soc Echocardiogr. 2015; 28: 210-217.e211-9
- Comparison of the hemodynamic performance of percutaneous and surgical bioprostheses for the treatment of severe aortic stenosis.J Am Coll Cardiol. 2009; 53: 1883-1891
- Enhanced left ventricular mass regression after aortic valve replacement in patients with aortic stenosis is associated with improved long-term survival.J Thorac Cardiovasc Surg. 2011; 142: 285-291
- Early regression of severe left ventricular hypertrophy after transcatheter aortic valve replacement is associated with decreased hospitalizations.JACC Cardiovasc Interv. 2014; 7: 662-673
- Regression of myocardial hypertrophy after aortic valve replacement: faster in women?.Circulation. 2010; 122: S23-S28
- Reduction in sample size for studies of remodeling in heart failure by the use of cardiovascular magnetic resonance.J Cardiovasc Magn Reson. 2000; 2: 271-278
- Impact of myocardial fibrosis in patients with symptomatic severe aortic stenosis.Circulation. 2009; 120: 577-584
- Severity of mitral and aortic regurgitation as assessed by cardiovascular magnetic resonance: optimizing correlation with Doppler echocardiography.J Cardiovasc Magn Reson. 2006; 8: 503-507
- Clinical utility and prognostic value of left atrial volume assessment by cardiovascular magnetic resonance in non-ischaemic dilated cardiomyopathy.Eur J Heart Fail. 2013; 15: 660-670
- CMR assessment of longitudinal left ventricular function following transcatheter aortic valve implantation for severe aortic stenosis.Society for Cardiovascular Magnetic Resonance/Euro CMR Joint Sessions. 2015; 17: 245
- Transcatheter versus surgical aortic-valve replacement in high-risk patients.N Engl J Med. 2011; 364: 2187-2198
- Midwall fibrosis is an independent predictor of mortality in patients with aortic stenosis.J Am Coll Cardiol. 2011; 58: 1271-1279
- Early effects of transcatheter aortic valve implantation and aortic valve replacement on myocardial function and aortic valve hemodynamics: insights from cardiovascular magnetic resonance imaging.J Thorac Cardiovasc Surg. 2015; 149: 462-470
- Left ventricular reverse remodeling after transcatheter aortic valve implantation: a cardiovascular magnetic resonance study.J Cardiovasc Magn Reson. 2013; 15: 39
- Discrepancies between echocardiographic measurements of left ventricular mass in a healthy adult population.Clin Sci (Lond). 1999; 97: 377-383
- Ex vivo cardiovascular magnetic resonance measurements of right and left ventricular mass compared with direct mass measurement in excised hearts after transplantation: a first human SSFP comparison.J Cardiovasc Magn Reson. 2014; 16: 74
- Hypertensive left ventricular hypertrophy: a mechanistic approach to optimizing regression assessed by cardiovascular magnetic resonance.J Hypertens. 2012; 30: 2039-2046
- Temporal regression of myocyte hypertrophy in hypertensive, heart failure-prone rats treated with an AT1-receptor antagonist.J Card Fail. 2002; 8: 43-47
- Left ventricular myocardial edema. Lymph flow, interstitial fibrosis, and cardiac function.Circ Res. 1991; 68: 1713-1721
- Quantification of cardiomyocyte hypertrophy by cardiac magnetic resonance: implications for early cardiac remodeling.Circulation. 2013; 128: 1225-1233
- Diffuse myocardial fibrosis - a therapeutic target? Proof of regression at 1-year following aortic valve replacement: the RELIEF-AS study.J Cardiovasc Magn Reson. 2016; 18: O37
- Progression from compensated hypertrophy to failure in the pressure-overloaded human heart: structural deterioration and compensatory mechanisms.Circulation. 2003; 107: 984-991
- Valve replacement for aortic stenosis normalizes subendocardial function in patients with normal ejection fraction.Eur J Echocardiogr. 2010; 11: 608-613
- A novel mechanism of heart failure with normal ejection fraction.Heart. 2008; 94: 446-449
Article info
Publication history
Published online: April 26, 2016
Accepted:
April 21,
2016
Received:
January 29,
2016
Footnotes
See editorial by Connelly et al., pages 1369–1371 of this issue.
See page 1417 for disclosure information.
Identification
Copyright
© 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
