Nadjiri Jonathan, Nieberler Hanna, Hendrich Eva, Will Albrecht, Pellegrini Costanza, Husser Oliver, Hengstenberg Christian, Greiser Andreas, Martinoff Stefan, Hadamitzky Martin
Department of Radiology and Nuclear Medicine, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636, Munich, Germany.
Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636, Munich, Germany.
Int J Cardiovasc Imaging. 2016 Nov;32(11):1625-1633. doi: 10.1007/s10554-016-0948-3. Epub 2016 Jul 26.
The benefit of a transcatheter aortic valve replacement (TAVR) can differ in patients, and therapy bears severe risks. High-degree aortic stenosis can lead to cardiac damage such as diffuse myocardial fibrosis, evaluable by extra-cellular volume (ECV) in CMR. Therefore, fibrosis might be a possible risk factor for unfavorable outcome after TAVR. We sought to assess the prognostic value of T1-mapping and ECV to predict adverse events during and after TAVR. The study population consisted of patients undergoing clinically indicated TAVR by performing additional CMR with native and contrast-enhanced T1-mapping sequences for additional evaluation of ECV. Study endpoints were congestive heart failure (CHF) and TAVR-associated conduction abnormalities defined as new onset of left bundle branch block (LBBB), AV-Block or implantation of a pacemaker. 94 patients were examined and followed. Median follow up time was 187 days (IQR 79-357 days). ECV was increased (>30 %) in 38 patients (40 %). There was no significant correlation between ECV and death, Hazard ratio (HR) 0.847 (95 % CI 0.335; 2.14), p = 0.72. ECV in patients with subsequent CHF was higher than in those without an event (33.5 ± 4.6 and 29.1 ± 4.1 %, respectively), but the difference just did not reach the level of significance HR 2.16 (95 % CI 0.969; 4.84), p = 0.06. Patients with post-TAVR conduction abnormality (LBBB, AV-block or pacemaker implantation) had statistically relevant lower ECV values compared to those without an event. Patients with an event had a mean ECV of 28.1 ± 3.16 %; patients without an event had a mean ECV of 29.8 ± 4.53, HR 0.56 (95 % CI 0.32; 0.96), p = 0.036. In this study, elevated myocardial ECV is a predictor of CHF by trend; CMR may be helpful in identifying patients with a high risk for post-TAVR cardiac decompensation benefitting from an intensified post-interventional surveillance. Patients with post-TAVR conductions abnormalities have a significantly decreased ECV. Nevertheless, it remains unclear which precise molecular tissue alteration is the protective factor or risk factor in this case.
经导管主动脉瓣置换术（TAVR）的益处因患者而异，且该治疗存在严重风险。高度主动脉瓣狭窄可导致心脏损害，如弥漫性心肌纤维化，可通过心脏磁共振成像（CMR）中的细胞外容积（ECV）进行评估。因此，纤维化可能是TAVR后不良预后的一个潜在危险因素。我们试图评估T1映射和ECV对预测TAVR期间及之后不良事件的预后价值。研究人群包括接受临床指征TAVR的患者，这些患者通过进行额外的CMR检查，采用天然和对比增强T1映射序列来进一步评估ECV。研究终点为充血性心力衰竭（CHF）和TAVR相关的传导异常，定义为新发左束支传导阻滞（LBBB）、房室传导阻滞或起搏器植入。对94例患者进行了检查和随访。中位随访时间为187天（四分位间距79 - 357天）。38例患者（40%）的ECV升高（>30%）。ECV与死亡之间无显著相关性，风险比（HR）为0.847（95%置信区间0.335；2.14），p = 0.72。随后发生CHF的患者的ECV高于未发生事件的患者（分别为33.5±4.6%和29.1±4.1%），但差异未达到显著水平，HR为2.16（95%置信区间0.969；4.84），p = 0.06。与未发生事件的患者相比，TAVR后发生传导异常（LBBB、房室传导阻滞或起搏器植入）的患者的ECV值在统计学上显著较低。发生事件的患者的平均ECV为28.1±3.16%；未发生事件的患者的平均ECV为29.8±4.53%，HR为0.56（95%置信区间0.32；0.96），p = 0.036。在本研究中，心肌ECV升高呈趋势性地是CHF的一个预测指标；CMR可能有助于识别TAVR后心脏失代偿风险高的患者，这些患者可能从强化的介入后监测中获益。TAVR后发生传导异常的患者的ECV显著降低。然而，目前仍不清楚在这种情况下哪种精确的分子组织改变是保护因素或危险因素。
