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Cardiac Remodeling in Patients With Aortic Regurgitation
Quick Takes
- Quantitative CMR measures of regurgitation severity and LV remodeling were associated with outcomes and could be useful in guiding management of asymptomatic chronic AR patients.
- CMR-based LV end-systolic volume assessment performed favorably compared to LV diameters.
- Additional studies are needed to determine how best to integrate data with clinical, echocardiographic, and CMR parameters to guide clinical management in asymptomatic chronic AR patients.
Study Questions:
What is the association of cardiac magnetic resonance (CMR) quantitative thresholds and outcomes in patients with aortic regurgitation (AR)?
Methods:
The investigators conducted a multicenter study of asymptomatic patients with moderate or severe AR on CMR with preserved left ventricular ejection fraction (LVEF). The primary outcome was development of symptoms or decrease in LVEF to <50%, guideline indications for surgery based on LV dimensions, or death under medical management. The secondary outcome was the same excluding surgery for remodeling indications. They excluded patients who underwent surgery within 30 days of CMR. Receiver-operating characteristic analyses for the association with outcome were performed.
Results:
A total of 458 patients were evaluated, with median age 60 years (interquartile range [IQR], 46-70 years). During a median follow-up of 2.4 years (IQR, 0.9, 5.3), 133 events occurred. Optimal thresholds were regurgitant volume of 47 mL and regurgitant fraction of 43%, indexed LV end-systolic (iLVES) volume of 43 mL/m2, indexed LV end-diastolic (iLVED) volume of 109 mL/m2, and iLVES diameter of 2 cm/m2. In multivariable regression analysis, iLVES volume ≥43 mL/m2 (hazard ratio, 2.53; 95% confidence interval, 1.75-3.66; p < 0.001) and iLVED volume ≥109 mL/m2 were independently associated with the outcomes and provided additional discrimination improvement over iLVES diameter, whereas iLVES diameter was independently associated with the primary outcome but not the secondary outcome.
Conclusions:
The authors report that in asymptomatic AR patients with preserved LVEF, CMR findings can be used to guide management.
Perspective:
This multicenter study of asymptomatic patients with chronic AR and preserved LV systolic function identified quantitative CMR measures of regurgitation severity and LV remodeling that were associated with outcomes and could be useful in guiding patient management. Furthermore, this study supports the use of LV volumes over LV diameters in patients with moderate or severe AR. Of note, this is a select group of patients referred for advanced imaging studies beyond echocardiography, and selection biases may apply to this cohort beyond the general AR population. Additional studies are needed to determine how best to integrate data with clinical, echocardiographic, and CMR parameters to guide clinical management.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Magnetic Resonance Imaging
Keywords: Aortic Valve Insufficiency, Cardiac Surgical Procedures, Diagnostic Imaging, Echocardiography, Heart Failure, Heart Valve Diseases, Magnetic Resonance Imaging, Secondary Prevention, Stroke Volume, Ventricular Function, Left
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