Short-term adverse remodeling progression in asymptomatic aortic stenosis.
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.
['Singh|Anvesha|A|http://orcid.org/0000-0003-1112-3973', 'Chan|Daniel C S|DCS|', 'Kanagala|Prathap|P|', 'Hogrefe|Kai|K|', 'Kelly|Damian J|DJ|', 'Khoo|Jeffery P|JP|', 'Sprigings|David|D|', 'Greenwood|John P|JP|', 'Abdelaty|Ahmed M S E K|AMSEK|', 'Jerosch-Herold|Michael|M|', 'Ng|Leong L|LL|', 'McCann|Gerry P|GP|']
D000368:Aged D001024:Aortic Valve Stenosis D003287:Contrast Media D004452:Echocardiography D005260:Female D005682:Gadolinium D006801:Humans D008297:Male D008875:Middle Aged D011446:Prospective Studies D016277:Ventricular Function, Left D020257:Ventricular Remodeling
Magnetic resonance imaging Fibrosis Aortic valve stenosis