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Left ventricular afterload and myocardial fibrosis in patients with severe symptomatic aortic stenosis: a multimodality study
Session:
Sessão de Comunicações Orais 12 – Doença Valvular Cardíaca: diagnóstico, estratificação de risco e abordagem terapêutica
Speaker:
Débora Da Silva Correia
Congress:
CPC 2026
Topic:
F. Valvular, Myocardial, Pericardial, Pulmonary, Congenital Heart Disease
Theme:
15. Valvular Heart Disease
Subtheme:
15.1 Valvular Heart Disease – Pathophysiology and Mechanisms
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Débora da Silva Correia; João Abecasis; Kamil Stankowski; Rita Lima; Samuel Azevedo; Telma Lima; Rita Reis Santos; Pedro Lopes; Sância Ramos; Regina Ribeiras; António Ferreira; Pedro Adragão
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Introduction:</strong> Left ventricular (LV) adaptation to increased afterload in patients with aortic stenosis (AS) is not only determined by valve obstacle but also by arterial impedance. As a compensatory response to maintain wall stress, LV remodeling occurs with myocardial changes that include fibrosis beyond hypertrophy. The impact of aortic stiffness, as a component of vascular load, to this adaptation remains poorly characterized.<br /> <br /> <strong>Aim: </strong>To assess the role of aortic stiffness, using aortic distensibility (AD) as a surrogate marker, in the myocardial tissue adaptation of the LV in patients with severe AS.<br /> <br /> <strong>Methods:</strong> Single-centre, prospective study of 158 patients with severe symptomatic AS (mean age 71±8 years; 50% male) undergoing surgical aortic valve replacement (SAVR) between 2019 and 2022. Patients with prior cardiomyopathy, significant aortic regurgitation, or other severe valve disease were excluded. All underwent TTE and CMR within 3 months before and after SAVR. Septal myocardial biopsies were harvested during surgery and analysed for myocardial fibrosis (MF) using Masson’s trichrome histochemistry. QuPath™ algorithm was applied for automatic MF quantification.<br /> <br /> Aortic dimensions were measured on cine CMR images at pulmonary artery bifurcation level in three-chamber and coronal left ventricular outflow tract views for the ascending aorta, and in the four-chamber view for the descending aorta. AD before and after SAVR was inferred. Valvulo-arterial impedance (Zva) and relative valve load (RVL) were also calculated. The correlation between AD and MF, as non-invasively assessed by CMR and at histopathology, was determined.<br /> <br /> <strong>Results:</strong> 128 patients with complete study were included (median age 73 years [69–77]; 48% male). Median AD was 1.4 [0.7–2.2] × 10?³ mmHg?¹, median Zva was 4.59 mmHg/mL/m² [3.76–5.14], and RVL was 13.5 mL/m² [10.9–16.7].<br /> <br /> Pre-operative CMR native T1 value was 1051 [1027–1071]ms; extracellular volume (ECV) fraction: 23.6 ± 4.8%. Non-ischemic late gadolinium enhancement (LGE) was present in 67% of patients, with a LGE percentage of 4.1% [1.6–6.9]. MF area was quantified at 1398163 [713204–3116924] µm², representing a median proportion of 12 [6–20]%.<br /> <br /> No significant correlations were found between AD and tissue characterization at CMR: T1 mapping (ρ= –0.183, p=0.044), LGE percentage (ρ=–0.192, p=0.079); ECV (ρ=–0.022, p=0.810). Similarly, AD showed no correlation with histological MF (ρ=–0.080, p=0.411, ρ=–0.129, p=0.185, for absolute area and proportion, respectively). Zva and RVL also showed no significant associations with either CMR tissue parameters or MF.<br /> <br /> <strong>Conclusion:</strong> In patients with classical severe symptomatic AS, myocardial tissue characterization at both pre-operative CMR and histology was unrelated to indexes of LV afterload. Additional factors determining tissue remodeling beyond the valve obstacle and arterial impedance are to be supposed.</span></span></p>
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