169 Mid-wall fibrosis is an independent predictor of mortality in patients with aortic stenosis

Introduction Predicting adverse clinical outcomes in aortic stenosis is challenging. Late gadolinium enhancement (LGE) has been associated with an adverse prognosis in a range of other cardiac conditions. Using late gadolinium enhancement, we sought to assess the prognostic significance of mid-wall and infarct patterns of myocardial fibrosis in aortic stenosis. Methods Between January 2003 and October 2008, consecutive patients with moderate or severe aortic stenosis (aortic valve area <1.5 cm2) underwent cardiovascular magnetic resonance with assessment of myocardial fibrosis by late gadolinium enhancement. Patients were categorised into absent, mid-wall or infarct patterns of late gadolinium enhancement by blinded independent observers. Patient follow-up was completed using the National Strategic Tracing Scheme. Results 143 patients (aged 68±14 years; 97 male) were followed up for 2.0±1.4 years. 81 patients had coronary artery disease, 72 underwent aortic valve replacement and 27 died. Compared to those with no late gadolinium enhancement (n=49), univariate analysis revealed that patients with mid-wall fibrosis (n=54) had an eightfold increase in all-cause mortality despite similar aortic stenosis severity and coronary artery disease burden. Patients with an infarct pattern (n=40) had a six-fold increase. Mid-wall fibrosis (HR, 5.35 (95% CI, 1.16 to 24.56); p=0.03) and ejection fraction (HR 0.96 (95% CI, 0.94 to 0.99); p=0.01) were independent predictors of all cause mortality by multivariate analysis. Conclusion: Mid-wall fibrosis is an independent predictor of mortality in patients with moderate and severe aortic stenosis. It has incremental prognostic value to ejection fraction and may provide a useful method of risk stratification in patients with advanced disease (Abstract 169 figure 1). Abstract 169 Figure 1 Kaplan-Meier curves of cardiac mortality (left) and all cause mortality (right) according to pattern of LGE (A= No LGE, B= Infarct LGE, C= Mid-wall LGE). Abstract 169 Table 1 No LGE Mid-wall LGE Infarct LGE p Value Number of patients 49 54 40 – Mean age yrs 64±16 70±11 70±13 0.031 Documented CAD % 37 42 98 <0.001 Ejection fraction % 69±13 58±21 44±18 <0.001 Aortic valve area 1.05±0.37 1.00±0.31 0.91±0.26 0.111 Indexed LV mass g/m2 92.6* (86.0, 99.6) 113.7* (104.5, 123.8) 97.8* (90.9, 105.2) 0.005 Mortality rate (deaths / 1000 pt years) 15.7 142.7 173.7 * Geometric mean (95%)