Prognostic impact of left ventricular reverse remodeling after surgical aortic valve replacement in severe aortic stenosis

Abstract

Surgical aortic valve replacement (SAVR) is the treatment of choice for young patients with severe aortic stenosis (AS). Left ventricular (LV) reverse remodeling (RR) after surgery is expected to occur, even though its definition is largely heterogenous and ill-defined. However, LV RR not always occurs following afterload relief, and such may impact the prognosis. Single-centre prospective study including patients referred for SAVR due to severe symptomatic AS, with no previous history of ischemic cardiomyopathy. Both pre- and post-operative transthoracic echocardiographic (TTE) and cardiac magnetic resonance (CMR) study (at the 3rd to 6th month after SAVR) were performed. LV RR was defined when in presence of at least one of the imaging criteria: >15% decrease in end-diastolic volume (CMR); >15% decrease in LV indexed mass (CMR); >10% decrease in geometric remodeling (LV mass/EDV ratio) by CMR; >10% increase in LV ejection fraction (CMR); >50% increase on global longitudinal strain (TTE). We assess the prognostic value of RR definitions for the outcome after SAVR using Cox regression and Kaplan-Meier analysis. The primary endpoint was defined as all-cause mortality, heart failure (HF) hospitalization or worsening HF. We enrolled 140 patients – mean age 71 ± 9 years-old, 49% male, predominantly high-gradient-normal flow AS submitted to SAVR. At a mean follow-up of 34 ± 12 months, 16% patients met the primary endpoint, with an overall mortality rate of 6%. Twelve patients (9%) were admitted for HF and 7 (5%) had at least one episode of worsening HF. 118 patients had complete pre and post-surgery imaging study (mean follow-up: 36 ± 10 months): 103 patients (87%) met at least one RR parameter. Post-operative RR was not independently associated with the primary endpoint. LV mass regression was the sole predictor of the outcome. LV RR after SAVR is highly prevalent in a cohort of patients with classical severe symptomatic AS. However, only LV mass regression independently predicts the clinical outcome after surgery. LV structural remodeling, rather than functional improvement after surgery, may better define the prognosis after pressure overload relief.