Abstract
To evaluate the association between histologically verified left ventricular (LV) myocardial fibrosis (MF) and its bio- and functional markers with pulmonary hypertension (PH) in severe aortic stenosis (AS). About 34 patients with isolated severe AS underwent 2D echocardiography, cardiac magnetic resonance (CMR) imaging, and plasma NT-proBNP evaluation before aortic valve replacement (AVR). LV measurements were analyzed by CMR and LV strain using feature tracking software (Medis Suite QStrain 2.0). Myocardial biopsy sampled at the time of AVR was assessed by a histomorphometric analysis. PH was defined as pulmonary artery systolic pressure (PASP) ⩾ 45 mm Hg. Patients with severe AS and PH (mean PASP 53 ± 3.7 mm Hg) had higher extent of diffuse MF versus patients without PH (12 (10.4-12.7)% vs 6.6 (4.6-8.2)% (p = 0.00)). The extent of diffuse MF correlated with LV dilatation (r = 0.7, p = 0.02), indices of LV dysfunction (lower ejection fraction (r = -0.6, p < 0.001), global longitudinal (r = -0.5, p = 0.02) and circumferential strain (r = -0.5, p = 0.05), elevated NT-proBNP (r = 0.5, p = 0.005) and elevated PASP (r = 0.6, p < 0.001)). Histological MF > 10% (AUC 94.9%), LV global longitudinal strain > -15.5% (AUC 86.3%), and NT-proBNP > 2090 ng/l (AUC 85.1%) were independent predictors of PH in severe AS. The extent of diffuse myocardial fibrosis in combination with reduced longitudinal left ventricular strain and increased plasma levels of NT-proBNP relates to pulmonary hypertension in severe aortic stenosis.
Highlights
The presence of pulmonary hypertension (PH) in patients with severe aortic stenosis (AS) is quite common and associated with poor prognosis, the identification of its determinants is clinically relevant.[1,2] The progression of AS grade leads to left ventricular (LV) hypertrophy, and the development of LV myocardial fibrosis (MF)
According to the presence or absence of PH, with pulmonary artery systolic pressure (PASP) cut-off value of 45 mm Hg derived by 2D echocardiography, nine patients (26.5%) had severe AS in combination with PH
The extent of left ventricular late gadolinium enhancement (LGE) midwall fibrosis area was larger in patients with PH (7.8 (5.6– 8.0)% vs 1.3 (1.2–1.48)%, p = 0.005)
Summary
The presence of pulmonary hypertension (PH) in patients with severe aortic stenosis (AS) is quite common and associated with poor prognosis, the identification of its determinants is clinically relevant.[1,2] The progression of AS grade leads to left ventricular (LV) hypertrophy, and the development of LV myocardial fibrosis (MF). These changes are supposed to affect the severity of LV remodeling and dysfunction.[3,4,5,6] the data of the MF impact in the development of PH in patients with severe AS is lacking. With the improvement of advanced imaging techniques together with the evaluation of plasma biomarker levels, it became possible to assess
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