Clinical Research
Heart Rhythm Disorder
Midwall Fibrosis Is an Independent Predictor of Mortality in Patients With Aortic Stenosis

https://doi.org/10.1016/j.jacc.2011.03.064Get rights and content
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Objectives

The goal of this study was to assess the prognostic significance of midwall and infarct patterns of late gadolinium enhancement (LGE) in aortic stenosis.

Background

Myocardial fibrosis occurs in aortic stenosis as part of the hypertrophic response. It can be detected by LGE, which is associated with an adverse prognosis in a range of other cardiac conditions.

Methods

Between January 2003 and October 2008, consecutive patients with moderate or severe aortic stenosis undergoing cardiovascular magnetic resonance with administration of gadolinium contrast were enrolled into a registry. Patients were categorized into absent, midwall, or infarct patterns of LGE by blinded independent observers. Patient follow-up was completed using patient questionnaires, source record data, and the National Strategic Tracing Service.

Results

A total of 143 patients (age 68 ± 14 years; 97 male) were followed up for 2.0 ± 1.4 years. Seventy-two underwent aortic valve replacement, and 27 died (24 cardiac, 3 sudden cardiac deaths). Compared with those with no LGE (n = 49), univariate analysis revealed that patients with midwall fibrosis (n = 54) had an 8-fold increase in all-cause mortality despite similar aortic stenosis severity and coronary artery disease burden. Patients with an infarct pattern (n = 40) had a 6-fold increase. Midwall fibrosis (hazard ratio: 5.35; 95% confidence interval: 1.16 to 24.56; p = 0.03) and ejection fraction (hazard ratio: 0.96; 95% confidence interval: 0.94 to 0.99; p = 0.01) were independent predictors of all-cause mortality by multivariate analysis.

Conclusions

Midwall fibrosis was an independent predictor of mortality in patients with moderate and severe aortic stenosis. It has incremental prognostic value to ejection fraction and may provide a useful method of risk stratification. (The Prognostic Significance of Fibrosis Detection in Cardiomyopathy; NCT00930735)

Key Words

aortic valve stenosis
gadolinium
mortality
myocardial fibrosis
myocardial infarction

Abbreviations and Acronyms

AVR
aortic valve replacement
CI
confidence interval
CMR
cardiovascular magnetic resonance
HR
hazard ratio
LGE
late gadolinium enhancement
LV
left ventricular
LVEDV
left ventricular end-diastolic volume
LVH
left ventricular hypertrophy

Cited by (0)

This research was supported by the National Institutes of Health Research Cardiovascular Biomedical Research Unit, a collaboration between Royal Brompton Hospital and Imperial College London. Support was also received from the British Heart Foundation and CORDA. Dr. Dweck was supported by a British Heart Foundation Fellowship Grant (FS/10/026). Dr. Jabbour was supported by the National Health and Medical Research Council of Australia, a Royal Australasian College of Physicians' Vincent Fairfax Family Foundation Research Fellowship, and the St. Vincent's Foundation. Dr. Cook has served as a consultant for GlaxoSmithKline. Dr. Pennell has served as a consultant for and received honoraria from Siemens, Novartis, and ApoPharma; and is a director and stockholder of Cardiovascular Imaging Solutions. Dr. Prasad has received honoraria from Schering. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Dweck and Joshi contributed equally to this work.