한빛사 논문
Hyun-Jung Lee MDa, Heesun Lee MDa, Sung Mok Kim MD, PhDb, Jun-Bean Park MD, PhDa, Eun Kyoung Kim MD, PhDc, Sung-A Chang MD, PhDc, Eunah Park MD, PhDd, Hyung-Kwan Kim MD, PhDa, Whal Lee MD, PhDd, Yong-Jin Kim MD, PhDa, Sang Chol Lee MD, PhDc, Seung Woo Park MD, PhDc, Dae-Won Sohn MD, PhDa, Jae K. Oh MDc,e, Sung-Ji Park MD, PhDc,∗, Seung-Pyo Lee MD, PhDa,∗
aDepartment of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
bDepartment of Radiology, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
cDivision of Cardiology, Department of Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
dDepartment of Radiology, Seoul National University Hospital, Seoul, South Korea
eDepartment of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
*Drs. S.-J. Park and S.-P. Lee contributed equally and are joint corresponding authors.
Address for correspondence: Dr. Sung-Ji Park, Dr. Seung-Pyo Lee
Abstract
Objectives
The aim of this study was to investigate the relationship between extracellular volume fraction (ECV), a noninvasive parameter that quantifies the degree of diffuse myocardial fibrosis on cardiac magnetic resonance (CMR), and left ventricular diastolic dysfunction (LVDD) in patients with aortic stenosis (AS).
Background
Myocardial fibrosis on invasive myocardial biopsy is associated with LVDD. However, there is a paucity of data on the association between noninvasively quantified diffuse myocardial fibrosis and the degree of LVDD and how these are related to symptoms and long-term prognosis in patients with AS.
Methods
Patients with moderate or severe AS (n = 191; mean age 68.4 years) and 30 control subjects without cardiovascular risk factors underwent CMR. LVDD grade was evaluated using echocardiography according to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Clinical outcomes were defined as a composite of all-cause mortality or hospitalization for heart failure aggravation.
Results
Patients in higher ECV quintiles had a significantly higher prevalence of LVDD. Higher ECV was particularly associated with decreased myocardial relaxation (septal e′ <7 cm/s) and increased LV filling pressure (E/e′ ratio ≥15). Although both impaired diastolic function and higher ECV were significantly associated with a worse degree of dyspnea, patients with higher ECV showed greater dyspnea within the same grade of LVDD. During a median follow-up period of 5.6 years, 37 clinical events occurred. Increased ECV, as well as lower septal e′ and higher E/septal e′ ratio, were independent predictors of clinical events, irrespective of age, AS severity, aortic valve replacement, and left ventricular (LV) ejection fraction. ECV provided incremental prognostic value on top of clinical factors and LV systolic and diastolic function.
Conclusions
Diffuse myocardial fibrosis, assessed using ECV on CMR, was associated with LVDD in patients with AS, but both ECV and LV diastolic function parameters provided a complementary explanation for dyspnea and clinical outcomes. Concomitant assessment of both LVDD and diffuse myocardial fibrosis may further identify patients with AS with greater symptoms and worse prognosis.
Key Words : aortic stenosis; diastole; fibrosis; cardiac magnetic resonance
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