scholarly journals Cardiac magnetic resonance and B-natriuretic peptide are superior prognostic tools to guideline-based echocardiography in asymptomatic patients with chronic severe aortic regurgitation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
R Kockova ◽  
H Linkova ◽  
Z Hlubocka ◽  
M Blaha ◽  
M Tuna ◽  
...  
Keyword(s):  
Magnetic Resonance ◽  
Disease Progression ◽  
Aortic Regurgitation ◽  
Natriuretic Peptide ◽  
Myocardial Fibrosis ◽  
Optimal Timing ◽  
Funding Source ◽  
Asymptomatic Patients ◽  
And Function ◽  
Surgical Group

Abstract Background The optimal timing of intervention in patients with chronic aortic regurgitation (AR) is currently based on patient symptoms and echocardiography derived parameters. The sensitivity of this approach is suboptimal and late operation often results in irreversible myocardial damage. Purpose To determine the prognostic value of novel parameters in asymptomatic patients with chronic severe AR in optimal timing of aortic valve surgery. Methods Consecutive patients with chronic severe AR not indicated for surgery per the current guidelines were studied in a prospective design in 5 centers. Baseline examination consisted of B-natriuretic peptide (BNP) measurement, comprehensive echocardiography (ECHO) including 3-dimensional (3D) study with vena contracta area (VCA), and complex magnetic resonance (MRI) including regurgitant volume (RV), regurgitant fraction (RF), global myocardial work efficiency (GWE) and extracellular volume (ECV); all analyzed in core lab. All patients were followed every 6 months and the endpoint was disease progression defined as an indication for surgery. The perioperative myocardial biopsy was performed in all surgically treated patients for histological myocardial fibrosis quantification. Results In total, 129 patients were enrolled between 2015 and 2019, the endpoint occurred in 35 patients during a mean follow-up of 1044 days. Baseline clinical data did not differ between patients with disease progression (surgical group) and stable patients. Baseline BNP levels were higher in the surgical group (63 vs. 20, P<0.01) and a cut-off value of 30.4 ng/L was predictive of disease progression with AUC 0.75. None of the standard ECHO parameters of left ventricular (LV) size and function was predictive of the endpoint. Novel ECHO parameter 3D VCA was higher in the surgical group (32 vs. 26 mm2, P=0.037). All MRI parameters of LV size and function were predictive of disease progression (all P<0.02), except LV ejection fraction. MRI-derived RV (57 vs. 37 ml, P<0.01) and RF (46 vs. 34%, P<0.01) were identified as the strongest independent predictors of surgery. There was no difference in ECV between the surgical group and stable patients (24 vs. 24, P=0.81) despite a good correlation with histological quantification of myocardial fibrosis. Conclusions Standard ECHO parameters cannot reliably predict the need for surgery in asymptomatic aortic regurgitation patients. Baseline BNP levels above 30.4 ng/L predict disease progression. Novel imaging parameters – ECHO-derived 3D VCA and MRI-derived parameters of LV size and AR severity might be useful in optimal timing determination. Imaging markers and myocardial histology Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Ministry of Health of the Czech Republic

scholarly journals Cardiac magnetic resonance and B-natriuretic peptide: prognostic value in patients with asymptomatic chronic aortic regurgitation

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
R Kockova ◽  
H Linkova ◽  
Z Hlubocka ◽  
M Blaha ◽  
M Tuna ◽  
...  
Keyword(s):  
Cardiac Magnetic Resonance ◽  
Magnetic Resonance ◽  
Disease Progression ◽  
Aortic Regurgitation ◽  
Regurgitant Volume ◽  
Severe Aortic Regurgitation ◽  
Asymptomatic Patients ◽  
Current Guidelines ◽  
Surgical Group

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by Ministry of Health of the Czech Republic 17-28265A. Background Indication for surgical treatment in asymptomatic patients with severe aortic regurgitation (AR) is curretly based on 2-dimensional echocardiography derived left ventricle (LV) diameter  and ejection fraction. Suboptimal sensitivity of this quideline-directed approach may lead to late intervention in a substantial number of patients. Purpose We aimed to develop a new prognostic stratification scheme based on novel imaging and biochemical markers of heart failure. Methods Consecutive patients with chronic severe AR not indicated for surgery per the current guidelines were enrolled into prospective multi-center study. Baseline examination consisted of B-natriuretic peptide (BNP); comprehensive echocardiography (ECHO) including 3-dimensional (3D) vena contracta area (VCA); comprehensive cardiac magnetic resonance (CMR) including regurgitant volume and fraction measurement, and extracellular volume (ECV); all imaging data were analysed in core lab. The perioperative myocardial biopsy from basal septum was performed in all surgically treated patients for histological myocardial fibrosis quantification by Picrosirius Red staining. Patient follow-up was every 6 months. The endpoint was a disease progression (indication for surgery per the current guidelines). Results In total, 132 patients were enrolled between 2015 and 2019, the endpoint occurred in 39 patients during a median follow-up of 1217 days. Baseline clinical data did not differ between patients with endpoint (surgical group) and stable patients (medical group). Baseline BNP levels were higher in the surgical group (57 vs. 20, P < 0.01). Most baseline ECHO parameters did not differ, only 3D VCA, mitral inflow E-wave and flow reversal velocity in the descending aorta were significantly different between two groups (33 vs. 25 mm2, 61 vs 68 cm/s, 21 vs. 19 cm/s with P = 0.012, P = 0.019, P = 0.001). Both CMR-derived end-systolic and end-diastolic LV volumes were significantly different (all P < 0.01); the LV ejection fraction was similar (61 vs. 61%, P = 0.83). The ECV was similar in both groups  (24.2 vs. 24%, P = 0.69) and correlated well with histologically validated diffuse myocardial fibrosis (15%). CMR-derived regurgitant volume and fraction were significantly higher in the surgical group (58 vs. 36 ml, P < 0.01 and 45 vs. 33%, P < 0.01). Based on our results, we developed a multi-factorial scoring system combining the independent predictors of disease progression (specificity 79%, sensitivity 74%).  Conclusion  Baseline CMR-derived LV volumes, CMR-derived regurgitant fraction, and BNP levels can predict disease progression in asymptomatic patients with chronic severe aortic regurgitation. The novel multi-factorial scoring system might identify candidates of early surgical treatment but this hypothesis will require prospective clinical testing. Abstract Figure. Cardiac magnetic resonance imaging

scholarly journals Proteoglycan remodeling is accelerated in women with angina pectoris and diffuse myocardial fibrosis: the iPOWER Study

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
N.D Mygind ◽  
S Holm Nielsen ◽  
M Mide Michelsen ◽  
A Pena ◽  
D Bechsgaard Frestad ◽  
...  
Keyword(s):  
Cardiac Magnetic Resonance ◽  
Magnetic Resonance ◽  
Angina Pectoris ◽  
Myocardial Fibrosis ◽  
T1 Mapping ◽  
Obstructive Coronary Artery Disease ◽  
Extracellular Volume ◽  
Diffuse Myocardial Fibrosis ◽  
Public Institution ◽  
Funding Source

Abstract Background Women with angina and no obstructive coronary artery disease (CAD) have an unfavourable prognosis, possibly due to coronary microvascular disease and diffuse myocardial fibrosis (DMF). In DMF myocardial extracellular matrix (ECM) proteins are actively remodeled by matrix metalloproteinase (MMP). Purpose We investigated MMP-mediated degradation of the protegoglycans biglycan and versican in women with angina pectoris and possible DMF assessed by cardiac magnetic resonance T1 mapping. Methods Seventy-one women with angina pectoris and no obstructive CAD were included. Asymptomatic age-matched women served as controls (n=32). Versican and biglycan were measured in serum by specific competitive enzyme-linked immunosorbent assays. T1 mapping was performed by cardiac magnetic resonance with gadolinium measuring T1 and extracellular volume (ECV). Results Both biglycan and versican levels were higher in symptomatic women compared with controls; 31.4 ng/mL vs. 16.4 ng/mL (p<0.001) and 2.1 ng/mL vs. 1.8 ng/mL (p<0.001), respectively (Figure 1) and were moderately correlated to global ECV (r2=0.38, p<0.001 and r2=0.26, p=0.015 respectively). Conclusion Turnover of biglycan and versican was increased in symptomatic compared to asymptomatic women and associated to ECV, supporting a link between angina with no obstructive CAD and fibrotic cardiac remodeling. The examined biomarkers may prove to be suitable for monitoring active ECM remodeling. Figure 1. Levels of BGM and VCANM Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): This work was supported by The Danish Heart Foundation, the Danish Research Fund (Den Danske Forskningsfond) and by University of Copenhagen.

Aortic regurgitation

ESC CardioMed ◽  
2018 ◽  
pp. 1634-1641
Author(s):  
Pilar Tornos Mas ◽  
Emmanuel Lansac
Keyword(s):  
Aortic Valve ◽  
Aortic Regurgitation ◽  
Aortic Surgery ◽  
Valve Surgery ◽  
Aortic Dilatation ◽  
Concomitant Surgery ◽  
Asymptomatic Patients ◽  
Aortic Pathology ◽  
Definition Of ◽  
And Function

Evaluation of aortic regurgitation requires consideration of valve morphology, mechanism and severity of regurgitation and assessment of aortic dilatation. In asymptomatic patients with severe aortic regurgitation, follow-up of symptomatic status and LV size and function is mandatory. The strongest indication for valve surgery is the presence of symptoms and/or the documentation of LVEF <50% and/or end-systolic diameter =50 mm. In patients with dilated aorta, definition of aortic pathology and accurate measurements of aortic diameters are crucial. Surgery is recommended whenever aortic dilation is = 55 mm or = 50 mm in patients with bicuspid aortic valves and Marfan syndrome or =45 mm when additional risk factors are present. For patients who have an indication for valve surgery, an aortic diameter of ≥45 mm is considered to indicate concomitant surgery of the aorta. Aortic valve repair and valve-sparing aortic surgery instead of aortic valve replacement should be considered in selected cases in experienced centres.

Aortic regurgitation

2015 ◽  
pp. 141-147
Author(s):  
Raphael Rosenhek
Keyword(s):  
Cardiac Magnetic Resonance ◽  
Magnetic Resonance ◽  
Aortic Valve ◽  
Aortic Regurgitation ◽  
Cardiac Computed Tomography ◽  
Transoesophageal Echocardiography ◽  
Left Ventricular ◽  
Disease Aetiology ◽  
Echocardiographic Parameters ◽  
And Function

The workup of patients with aortic regurgitation is routinely based on echocardiography and includes a detailed morphologic assessment of the aortic valve with the determination of disease aetiology. The quantification of aortic regurgitation is based on an integration of qualitative and quantitative parameters. Haemodynamic consequences of aortic valve disease on left ventricular size, hypertrophy, and function, as well as potentially coexisting valve lesions, are assessed. Predictors of outcome and indications for surgery are substantially defined by echocardiographic parameters. Cardiac magnetic resonance has become an important complementary technique, both for the quantification of regurgitant severity and for the assessment of ventricular function. While the proximal parts of the ascending aorta are routinely visualized by transthoracic echocardiography, transoesophageal echocardiography (TOE) and in particular cardiac magnetic resonance (CMR) and cardiac computed tomography (CT) allow a more comprehensive assessment of the thoracic aorta.

scholarly journals New Imaging Markers of Clinical Outcome in Asymptomatic Patients with Severe Aortic Regurgitation

2019 ◽  
Vol 8 (10) ◽  
pp. 1654
Author(s):  
Radka Kočková ◽  
Hana Línková ◽  
Zuzana Hlubocká ◽  
Alena Pravečková ◽  
Andrea Polednová ◽  
...  
Keyword(s):  
Aortic Regurgitation ◽  
Early Stage ◽  
Laboratory Data ◽  
Left Ventricular ◽  
Vena Contracta ◽  
Severe Aortic Regurgitation ◽  
End Diastolic Volume ◽  
Asymptomatic Patients ◽  
Imaging Markers ◽  
And Function

Background: Determining the value of new imaging markers to predict aortic valve (AV) surgery in asymptomatic patients with severe aortic regurgitation (AR) in a prospective, observational, multicenter study. Methods: Consecutive patients with chronic severe AR were enrolled between 2015–2018. Baseline examination included echocardiography (ECHO) with 2- and 3-dimensional (2D and 3D) vena contracta area (VCA), and magnetic resonance imaging (MRI) with regurgitant volume (RV) and fraction (RF) analyzed in CoreLab. Results: The mean follow-up was 587 days (interquartile range (IQR) 296–901) in a total of 104 patients. Twenty patients underwent AV surgery. Baseline clinical and laboratory data did not differ between surgically and medically treated patients. Surgically treated patients had larger left ventricular (LV) dimension, end-diastolic volume (all p < 0.05), and the LV ejection fraction was similar. The surgical group showed higher prevalence of severe AR (70% vs. 40%, p = 0.02). Out of all imaging markers 3D VCA, MRI-derived RV and RF were identified as the strongest independent predictors of AV surgery (all p < 0.001). Conclusions: Parameters related to LV morphology and function showed moderate accuracy to identify patients in need of early AV surgery at the early stage of the disease. 3D ECHO-derived VCA and MRI-derived RV and RF showed high accuracy and excellent sensitivity to identify patients in need of early surgery.

scholarly journals P1578 The prognostic value of left ventricle longitudinal strain and cardiac biomarkers in asymptomatic patients with chronic severe aortic regurgitation

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
R Verseckaite ◽  
D Vaiciuliene ◽  
J Laukaitiene ◽  
R Jonkaitiene ◽  
V Mizariene ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Left Ventricle ◽  
Aortic Regurgitation ◽  
Primary Endpoint ◽  
Longitudinal Strain ◽  
Cardiac Biomarkers ◽  
Optimal Timing ◽  
Severe Aortic Regurgitation ◽  
Asymptomatic Patients

Abstract Background Because of adaptive remodelling of the left ventricle (LV), patients with chronic severe aortic regurgitation (AR) can remain asymptomatic for prolonged periods. The main clinical challenge is to avoid irreversible damage to the myocardium and LV dysfunction, but the time of surgery should be such that the benefits of surgery outweigh the risks at that particular time. We aimed to evaluate the predictive value of global LV longitudinal strain (GLS) and natriuretic peptide in severe AR. Methods Comprehensive and 2D speckle tracking echocardiography was performed in 84 patients with severe AR. Patients were divided into the asymptomatic group (n = 56; 41 men; mean age 46.1 ± 15.4 years) and the group with indications for AV surgery (n = 28; 27 men; mean age 49.0 ± 14.3 years). Asymptomatic patients were followed for about 4.4 ± 2.4 years. The primary endpoint was to detect the development of HF symptoms, deterioration in the LVEF(≤50%) and/or severe LV dilatation (EDD &gt; 70mm or ESS &gt; 50mm). Results Patients with the need of AV surgery showed a significantly larger impairment in GLS and higher increase in the values of NT-proBNP compared to asymptomatic patients (-17.2 ± 2.6 vs. -19.1 ± 2.4%, and 149.4 [86.6–500] vs. 112.5 [45.3–180.8]pg/mL, P &lt; 0.05, resp.). Of the 56 patients who were initially asymptomatic, 49 patients were prospectively monitored. The primary endpoint was reached in 16 (33%) patients with AR. Despite the preserved LVEF at baseline, patients in need of AV surgery had lower GLS compared to those who remained stable while being monitored (-17.1 ± 2.3 vs. -20.1 ± 1.8%, P &lt; 0.05). The baseline levels of NT-proBNP were higher among patients who progressed to needing AV surgery in comparison to that in no need of AV surgery at follow-up (194 [135-421.8] vs. 75.9 [34.1-136.7]pg/ml, P &lt; 0.05). In multivariate analysis, GLS and NT-proBNP were independent predictors of AV surgery. ROC analysis showed that the probability of primary endpoint occurrence was greater in patients with GLS &gt;-18.5% (AUC:0.85, P &lt; 0.05) and NT-proBNP &gt;130pg/ml (AUC:0.81, P &lt; 0.05). Conclusion GLS and NT-proBNP may be used as independent prognostic predictors of optimal timing of operation in asymptomatic severe AR during follow-up. Multivariate analysis Variables OR (95% CI) P Age 0.97 (0.89-1.06) 0.54 LV ESD 1.02 (0.78-1.34) 0.87 LV EF 1.07 (0.74-1.56) 0.71 GLS 3.36 (1.09-10.36) 0.035 NT-proBNP 1.02 (1.0-1.04) 0.049

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