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Curso de Atualização em Medicina Cardiovascular 2019
Reunião Anual Conjunta dos Grupos de Estudo de Cirurgia Cardíaca, Doenças Valvulares e Ecocardiografia da SPC
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Impact of myocardial fibrosis in left ventricular remodeling after aortic valve replacement (AVR) for severe aortic stenosis (AS)
Session:
CO 11 - Imagiologia Cardíaca
Speaker:
Cláudio Guerreiro
Congress:
CPC 2018
Topic:
B. Imaging
Theme:
03. Imaging
Subtheme:
03.3 Cardiac Magnetic Ressonance
Session Type:
Comunicações Orais
FP Number:
---
Authors:
CM Espada Guerreiro; Jennifer Mâncio; Nuno Dias Ferreira; David Monteiro; Nuno Almeida; Pedro Rodrigues; Wilson Ferreira; Mónica Carvalho; Rita Faria; Ricardo Ladeiras-Lopes; Luís Vouga; Vasco Gama Ribeiro; Nuno Bettencourt
Abstract
<p><strong>Introduction</strong></p> <p>In severe AS patients, the heart remodels to adapt to the increased afterload leading to LV hypertrophy, ultimately resulting in myocardial fibrosis. Timeless AVR prevents replacement fibrosis progression, but how the quantity of myocardial fibrosis affects the remodelling after surgery limiting its potential benefits is unknown.</p> <p> </p> <p><strong>Objectives</strong></p> <p>To evaluate the impact of late-gadolinium enhancement (LGE) by CMR imaging on indexed LV mass (LVMi) regression 6 months after AVR.</p> <p> </p> <p><strong>Methods</strong></p> <p>Prospective cohort of 62 severe AS patients with preserved LVEF referred for AVR that underwent CMR at baseline. We performed a paired analysis with those who also undergone CMR at 6-months after AVR. LGE scan protocol was performed to identify segments of replacement fibrosis. LVMi regression was defined as reduction of LVMi measured by CMR above 10% at 6-month follow-up (FUP). Comparisons were made between patients with and without LVMi regression.</p> <p> </p> <p><strong>Results</strong></p> <p>32 patients had paired CMR at baseline and at 6-month follow-up (age 70±8.3 years; 66% males). Overall obstructive CAD (more than 1 stenosis higher than 70%) was observed in 9 patients (28.1%). A bioprosthesis was implanted in 25 patients (78.1%). An additional CABG was performed in 7 (21.9%) patients. After surgery, a significant reduction in the mean transvalvular gradient was observed (49.4±11.6mmHg to 9.6±4.0mmHg; p<0.001).</p> <p>LVMi decreased from 91±22.0 g/m<sup>2 </sup>at baseline to 70±15.9 g/m<sup>2</sup> at 6 months FUP (P<0.001), as mass/volume ratio from 1.09±0.28 to 0.98±0.19 (p=0.037). LV volumes decreased after surgery (LVEDVi 86.0±25.6 mL/m<sup>2</sup> vs. 73.3±16.3 mL/m<sup>2</sup>, P=0.009; LVESVi 32.5±17.5 mL/m<sup>2</sup> vs. 27.0±10.6 mL/m<sup>2</sup>, p=0.076), and no change was observed in LVEF (62.4±8.0% to 62.4±7.1%, p=0.986).</p> <p>LVMi regression occurred in 78% of patients. Patients with LVMi regression had higher baseline LVMi (95.2±22.18 vs. 74.0±11.4, p=0.022), lower LV volumes at FUP (LVEDVi 69.8±15.1 vs. 85.8±14.8mL/m2, p=0.019; LVESV 46.4±16.8 vs. 63.7±22.0mL/m2, p=0.032), higher LVEF (63.7±6.5 vs. 57.5±7.1, p=0.040). No differences were found in the distribution or number of segments affected by LGE at baseline and the occurrence of the endpoint LVMi regression (mean 1.13 (6.6%) vs. 1.00 (5.9%), P=0.830). At 6 months after surgery, the extension of late enhancement remained unchanged (p=0.180).</p> <p>After adjustment for age, gender, presence of CAD, baseline LVMi and gradient change after surgery, the number of segments with LGE was not associated with LVMi regression (OR 0.39, 95%CI 0.10-1.47, p=0.167). The only factor associated with LVMi regression was baseline LVMi.</p> <p> </p> <p><strong>Conclusions</strong></p> <p>After 6 months from aortic valve replacement for severe aortic stenosis, significant LVM regression occurs. The extension and pattern of distribution of baseline LGE remained unchanged at follow up. Importantly, the presence of LGE was not associated with a negative impact in preventing LV mass regression. </p>
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