Abstract
The left ventricular (LV) remodeling process associated with significant valvular heart disease (VHD) is characterized by an increase of myocardial interstitial space with deposition of collagen and loss of myofibers. These changes occur before LV systolic function deteriorates or the patient develops symptoms. Cardiovascular magnetic resonance (CMR) permits assessment of reactive fibrosis, with the use of T1 mapping techniques, and replacement fibrosis, with the use of late gadolinium contrast enhancement. In addition, functional consequences of these structural changes can be evaluated with myocardial tagging and feature tracking CMR, which assess the active deformation (strain) of the LV myocardium. Several studies have demonstrated that CMR techniques may be more sensitive than the conventional measures (LV ejection fraction or LV dimensions) to detect these structural and functional changes in patients with severe left-sided VHD and have shown that myocardial fibrosis may not be reversible after valve surgery. More important, the presence of myocardial fibrosis has been associated with lesser improvement in clinical symptoms and recovery of LV systolic function. Whether assessment of myocardial fibrosis may better select the patients with severe left-sided VHD who may benefit from surgery in terms of LV function and clinical symptoms improvement needs to be demonstrated in prospective studies. The present review article summarizes the current status of CMR techniques to assess myocardial fibrosis and appraises the current evidence on the use of these techniques for risk stratification of patients with severe aortic stenosis or regurgitation and mitral regurgitation.
Highlights
Valvular heart disease (VHD) is an important public-health problem with an increasing prevalence along with ageing of the population [1]
This article provides an overview of current Cardiovascular magnetic resonance (CMR) techniques to assess myocardial fibrosis in patients with left-sided VHD
Midwall fibrosis on late gadolinium enhancement (LGE) CMR was associated with higher mortality than infarct-type LGE (HR 8.59; 95% CI 1.97–37.38; p = 0.004 and HR 6.46; 95% CI 1.39-30.00; p = 0.017, respectively)
Summary
Valvular heart disease (VHD) is an important public-health problem with an increasing prevalence along with ageing of the population [1]. Patients with symptomatic severe VHD and in asymptomatic patients with reduced left ventricular (LV) ejection fraction, LV dilatation, pulmonary hypertension, right ventricular dilatation and dysfunction and presence of atrial fibrillation [1, 3]. Most of these adverse consequences of severe VHD are observed in advanced stages of the disease and are partially irreversible after intervention, leading to suboptimal long-term clinical outcomes [4]. This article provides an overview of current CMR techniques to assess myocardial fibrosis in patients with left-sided VHD. One of the most commonly used in clinical practice is the modified Look-Locker pulse sequence where multiple single-shot images are acquired intermittently in diastole during 9–17 cardiac cycles and the inversion recovery curves are
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