Key result
Aortic valve replacement was associated with substantial reverse remodeling at 7 months, including a 44% reduction in LV end-diastolic volume and a 21% reduction in LV mass (both P<0.001).
Why the study?
Patients undergoing AVR for chronic severe AR based on current guideline thresholds may have irreversible myocardial scarring, and its relationship with incomplete recovery was unclear.
Does aortic valve replacement improve left ventricular reverse remodeling and how does preoperative myocardial fibrosis affect recovery in patients with chronic severe aortic regurgitation?
Observational (n=72)
Yes
Does aortic valve replacement improve left ventricular reverse remodeling and how does preoperative myocardial fibrosis affect recovery in patients with chronic severe aortic regurgitation?
p-value: p=<.001
Aortic valve replacement for chronic severe aortic regurgitation leads to significant reverse remodeling at 7 months, but preoperative focal scar is associated with incomplete recovery.
Myocardial fibrosis may identify AR patients with incomplete post-AVR recovery; leaves open whether fibrosis assessment should guide surgical timing.
Importance Patients undergoing aortic valve replacement (AVR) for chronic severe aortic regurgitation (AR) based on current guideline-based thresholds may have irreversible myocardial scarring. Objective To quantify reverse remodeling, functional recovery, and symptomatic change after AVR and assess whether myocardial fibrosis is associated with incomplete recovery. Design, Setting, and Participants In this prospective longitudinal observational study, patients with chronic severe AR referred for AVR by a cardiology team were included. Key exclusion criteria were previous valve surgery, moderate or greater valve disease, and other primary cardiomyopathies. Included patients underwent paired biomarkers, echocardiography, cardiopulmonary exercise testing, and cardiovascular magnetic resonance (CMR) at baseline and at a median of 7 months after AVR. The study took place at 2 tertiary cardiothoracic centers in London, United Kingdom, with enrollment from August 2021 to October 2023. Data were analyzed from January to April 2026. Exposure AVR. Main Outcomes and Measures Left ventricular (LV) reverse remodeling (change in LV end-diastolic volume [LVEDV] and LV mass) post-AVR and preoperative correlates of incomplete recovery, with prespecified focus on CMR fibrosis markers (late gadolinium enhancement [LGE] and extracellular volume [ECV]). Results Seventy-two patients (median [IQR] age, 60 [6-70] years; 59 [82%] male, 35 [49%] with bicuspid aortic valve) completed paired studies. Median (IQR) regurgitant volume fell from 61 (38-83) mL to 5 (3-8) mL; median (IQR) LVEDV fell 44% from 273 (211-307) mL to 153 (130-177) mL; and median (IQR) LV mass fell 21% from 200 (159-226) g to 158 (137-184) g (all P < .001). Indexed intracellular volume declined 21% and indexed extracellular volume 15% (26 mL/m 2 to 22 mL/m 2 ; P < .001), raising extracellular volume fraction (ECV%) from 27.4% to 29.1% ( P < .001). LGE as a percentage of LV mass was unchanged (2.3% to 2.4%; P = .36); baseline LGE burden was associated with less regression of LV mass (χ 2 2 = 29.4; P < .001) and LVEDV at 7 months (χ 2 1 = 7.9; P = .007). New York Heart Association class and quality of life improved (median [IQR] EQ-5D index improved from 0.89 [0.78-1.00] to 0.94 [0.81-1.00]; P < .001), but maximum oxygen consumption was unchanged (22.6 mL/kg/min to 21 mL/kg/min; P = .08). N-terminal pro–B-type natriuretic peptide decreased slightly (228 pg/mL to 198 pg/mL; P = .27), with a larger fall in patients with evidence of decompensation (n = 31; 469 pg/mL to 279 pg/mL; P = .02). Conclusions and Relevance In this study, AVR was associated with substantial reverse remodeling at 7 months, including regression of hypertrophy and a fall in indexed extracellular (matrix) volume; the extracellular volume fraction rose, as cellular regression outpaced matrix regression. Focal scar, as a proportion of myocardium, was unchanged. Preoperative focal scar was independently associated with less recovery and may mark incomplete remodeling. Objective functional recovery did not improve at this time point.
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Thornton et al. (2026) conducted an observational in Chronic severe aortic regurgitation (n=72). Aortic valve replacement was evaluated on Left ventricular (LV) reverse remodeling (change in LV end-diastolic volume and LV mass) post-AVR and preoperative correlates of incomplete recovery (p=<.001). Aortic valve replacement was associated with substantial reverse remodeling at 7 months, including a 44% reduction in LV end-diastolic volume and a 21% reduction in LV mass (both P<0.001).