Extracellular Myocardial Volume in Patients With Aortic Stenosis

Russell J. Everett, Thomas A. Treibel, Miho Fukui, Heesun Lee, Marzia Rigolli, Anvesha Singh, Petra Bijsterveld, Lionel Tastet, Tarique Al Musa, Laura Dobson, Calvin Chin, Gabriella Captur, Sang Yong Om, Stephanie Wiesemann, Vanessa M. Ferreira, Stefan K. Piechnik, Jeanette Schulz-Menger, Erik B. Schelbert, Marie-Annick Clavel, David E. NewbySaul G. Myerson, Phillipe Pibarot, Sahmin Lee, João L. Cavalcante, Seung-Pyo Lee, Gerry P. McCann, John P. Greenwood, James C. Moon, Marc R. Dweck

Research output: Contribution to journalArticlepeer-review

Abstract / Description of output

Background: Myocardial fibrosis is a key mechanism of left ventricular decompensation in aortic stenosis and can be quantified using cardiovascular magnetic resonance (CMR) measures such as extracellular volume fraction (ECV%). Outcomes following aortic valve intervention may be linked to the presence and extent of myocardial fibrosis.

Objectives: This study sought to determine associations between ECV% and markers of left ventricular decompensation and post-intervention clinical outcomes.

Methods: Patients with severe aortic stenosis underwent CMR, including ECV% quantification using modified Look-Locker inversion recovery–based T1 mapping and late gadolinium enhancement before aortic valve intervention. A central core laboratory quantified CMR parameters.

Results: Four-hundred forty patients (age 70 ± 10 years, 59% male) from 10 international centers underwent CMR a median of 15 days (IQR: 4 to 58 days) before aortic valve intervention. ECV% did not vary by scanner manufacturer, magnetic field strength, or T1 mapping sequence (all p > 0.20). ECV% correlated with markers of left ventricular decompensation including left ventricular mass, left atrial volume, New York Heart Association functional class III/IV, late gadolinium enhancement, and lower left ventricular ejection fraction (p < 0.05 for all), the latter 2 associations being independent of all other clinical variables (p = 0.035 and p < 0.001). After a median of 3.8 years (IQR: 2.8 to 4.6 years) of follow-up, 52 patients had died, 14 from adjudicated cardiovascular causes. A progressive increase in all-cause mortality was seen across tertiles of ECV% (17.3, 31.6, and 52.7 deaths per 1,000 patient-years; log-rank test; p = 0.009). Not only was ECV% associated with cardiovascular mortality (p = 0.003), but it was also independently associated with all-cause mortality following adjustment for age, sex, ejection fraction, and late gadolinium enhancement (hazard ratio per percent increase in ECV%: 1.10; 95% confidence interval [1.02 to 1.19]; p = 0.013).

Conclusions: In patients with severe aortic stenosis scheduled for aortic valve intervention, an increased ECV% is a measure of left ventricular decompensation and a powerful independent predictor of mortality.
Original languageEnglish
Pages (from-to)304-316
JournalJournal of the American College of Cardiology
Issue number3
Early online date20 Jan 2020
Publication statusPublished - 28 Jan 2020


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