Abstract
AimsAsymmetric wall thickening has been described in patients with aortic stenosis. However, it remains poorly characterized and its prognostic implications are unclear. We hypothesized this pattern of adaptation is associated with advanced remodelling, left ventricular decompenzation, and a poor prognosis.Methods and resultsIn a prospective observational cohort study, 166 patients with aortic stenosis (age 69, 69% males, mean aortic valve area 1.0 ± 0.4 cm2) and 37 age and sex-matched healthy volunteers underwent phenotypic characterization with comprehensive clinical, imaging, and biomarker evaluation. Asymmetric wall thickening on both echocardiography and cardiovascular magnetic resonance was defined as regional wall thickening ≥ 13 mm and > 1.5-fold the thickness of the opposing myocardial segment. Although no control subject had asymmetric wall thickening, it was observed in 26% (n = 43) of patients with aortic stenosis using magnetic resonance and 17% (n = 29) using echocardiography. Despite similar demographics, co-morbidities, valve narrowing, myocardial hypertrophy, and fibrosis, patients with asymmetric wall thickening had increased cardiac troponin I and brain natriuretic peptide concentrations (both P < 0.001). Over 28 [22, 33] months of follow-up, asymmetric wall thickening was an independent predictor of aortic valve replacement (AVR) or death whether detected by magnetic resonance [hazard ratio (HR) = 2.15; 95% confidence interval (CI) 1.29–3.59; P = 0.003] or echocardiography (HR = 1.79; 95% CI 1.08–3.69; P = 0.021).ConclusionAsymmetric wall thickening is common in aortic stenosis and is associated with increased myocardial injury, left ventricular decompenzation, and adverse events. Its presence may help identify patients likely to proceed quickly towards AVR.Clinical Trial Registration: https://clinicaltrials.gov/show/NCT01755936: NCT01755936.
Highlights
IntroductionAortic stenosis is characterized by progressive valve narrowing and by the hypertrophic response of the left ventricle (LV) that ensues
Aortic stenosis is characterized by progressive valve narrowing and by the hypertrophic response of the left ventricle (LV) that ensues.1 the development of symptoms and adverse events appears as much related to events in the myocardium as the valve.2 New techniques for assessing adverse patterns of remodelling are of major interest.3Echocardiography is the most common imaging technique to assess patients with aortic stenosis and can provide assessments of wall thickness that can be used to calculate left ventricular mass index
A comprehensive overview of patients’ demographics, aortic stenosis severity, left ventricular characteristics, and co-morbidities as well as comparisons to healthy controls can be found in Table 1 and Supplementary data online
Summary
Aortic stenosis is characterized by progressive valve narrowing and by the hypertrophic response of the left ventricle (LV) that ensues.. Echocardiography is the most common imaging technique to assess patients with aortic stenosis and can provide assessments of wall thickness that can be used to calculate left ventricular mass index. Cardiovascular magnetic resonance is less widely employed but provides the gold standard assessment of left ventricular mass and wall thickness with the unique ability to identify myocardial fibrosis. Asymmetric wall thickening is most commonly associated with hypertrophic cardiomyopathy.. Asymmetric wall thickening is most commonly associated with hypertrophic cardiomyopathy.4 This form of remodelling has recently been described in patients with increased afterload such as hypertension and aortic stenosis.. An initial magnetic resonance study suggested that asymmetric wall thickening could be observed in around a quarter of patients. This study was hampered by referral bias and did not involve detailed tissue characterization. Echocardiographic studies have suggested a lower prevalence of around 10%, with the prognostic implications of this observation remaining unclear.
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