MULTI-MODALITY IMAGING IN AORTIC STENOSIS:AN EACVI CLINICAL CONSENSUS DOCUMENT

International audienceIn this EACVI clinical scientific update, we will explore the current use of multi-modality imaging in the diagnosis, risk stratification, and follow-up of patients with aortic stenosis, with a particular focus on recent developments and future directions. Echocardiography is and will likely remain the key method of diagnosis and surveillance of aortic stenosis providing detailed assessments of valve haemodynamics and the cardiac remodelling response. Computed tomography (CT) is already widely used in the planning of transcutaneous aortic valve implantation. We anticipate its increased use as an anatomical adjudicator to clarify disease severity in patients with discordant echocardiographic measurements. CT calcium scoring is currently used for this purpose; however, contrast CT techniques are emerging that allow identification of both calcific and fibrotic valve thickening. Additionally, improved assessments of myocardial decompensation with echocardiography, cardiac magnetic resonance, and CT will become more commonplace in our routine assessment of aortic stenosis. Underpinning all of this will be widespread application of artificial intelligence. In combination, we believe this new era of multi-modality imaging in aortic stenosis will improve the diagnosis, follow-up, and timing of intervention in aortic stenosis as well as potentially accelerate the development of the novel pharmacological treatments required for this disease

Extracellular Myocardial Volume in Patients With Aortic Stenosis

BACKGROUND: Myocardial fibrosis is a key mechanism of left ventricular decompensation in aortic stenosis and can be quantified using cardiovascular magnetic resonance (CMR) measures such as extracellular volume fraction (ECV%). Outcomes following aortic valve intervention may be linked to the presence and extent of myocardial fibrosis. OBJECTIVES: This study sought to determine associations between ECV% and markers of left ventricular decompensation and post-intervention clinical outcomes. METHODS: Patients with severe aortic stenosis underwent CMR, including ECV% quantification using modified Look-Locker inversion recovery-based T1 mapping and late gadolinium enhancement before aortic valve intervention. A central core laboratory quantified CMR parameters. RESULTS: Four-hundred forty patients (age 70 ± 10 years, 59% male) from 10 international centers underwent CMR a median of 15 days (IQR: 4 to 58 days) before aortic valve intervention. ECV% did not vary by scanner manufacturer, magnetic field strength, or T1 mapping sequence (all p > 0.20). ECV% correlated with markers of left ventricular decompensation including left ventricular mass, left atrial volume, New York Heart Association functional class III/IV, late gadolinium enhancement, and lower left ventricular ejection fraction (p < 0.05 for all), the latter 2 associations being independent of all other clinical variables (p = 0.035 and p < 0.001). After a median of 3.8 years (IQR: 2.8 to 4.6 years) of follow-up, 52 patients had died, 14 from adjudicated cardiovascular causes. A progressive increase in all-cause mortality was seen across tertiles of ECV% (17.3, 31.6, and 52.7 deaths per 1,000 patient-years; log-rank test; p = 0.009). Not only was ECV% associated with cardiovascular mortality (p = 0.003), but it was also independently associated with all-cause mortality following adjustment for age, sex, ejection fraction, and late gadolinium enhancement (hazard ratio per percent increase in ECV%: 1.10; 95% confidence interval [1.02 to 1.19]; p = 0.013). CONCLUSIONS: In patients with severe aortic stenosis scheduled for aortic valve intervention, an increased ECV% is a measure of left ventricular decompensation and a powerful independent predictor of mortality

Surgical and interventional management of mitral valve regurgitation: a position statement from the european society of cardiology working groups on cardiovascular surgery and valvular heart disease

Surgical and interventional treatment for mitral regurgitation (MR) requires a multidisciplinary approach. Experienced operators in high volume centers with a dedicated Heart Team obtain best outcomes. Surgical repair is the reference standard treatment in primary MR. Timely surgery is associated with excellent outcome and restoration of normal life expectancy. Percutaneous procedures should be reserved for high-risk or inoperable symptomatic patients. The choice of treatment in secondary MR is more controversial: Surgical correction can improve symptoms and quality of life, and reverse left ventricular (LV) remodelling in selected patients. However, a clear prognostic benefit in comparison with optimal medical therapy has not been demonstrated. Undersized annuloplasty might offer a satisfactory result if performed before the onset of severe LV dilatation and in the absence of echocardiographic predictors of post-operative residual or recurrent MR. Otherwise, mitral valve (MV) replacement with preservation of the sub-valvular apparatus is preferable. Percutaneous edge-to-edge (EE) repair for secondary MR is a low-risk option to reduce symptoms and induce reverse LV remodelling but is commonly associated with residual and recurrent MR. The procedure should be reserved for patients who have significant symptoms despite optimal heart failure therapy (including cardiac resynchronisation where appropriate), are judged to be at excessive risk for MV surgery by a Heart Team, fulfil the echocardiographic criteria of eligibility, and do not have existing comorbidities to preclude the benefits of correction or reduction of MR. Ongoing trials in patients with isolated secondary MR will define whether percutaneous EE repair has a significant role in the management of heart failure. Randomized studies are needed to clarify whether correction of MR in high-risk patients provides clinical and prognostic benefit in comparison with optimal medical therapy