Key result
Preoperative right ventricular dysfunction (RVEF <50%) was associated with a 2.5-fold increase in all-cause mortality after aortic valve replacement (HR 2.5; 95% CI 1.6-3.9; p<0.0001).
Why the study?
The right ventricle is understudied and not routinely assessed in aortic stenosis, though RV afterload and function may be clinically important and detectable by CMR.
Does preoperative right ventricular dysfunction predict all-cause mortality in patients with severe aortic stenosis undergoing aortic valve replacement?
Cohort (n=666)
Yes
Does preoperative right ventricular dysfunction predict all-cause mortality in patients with severe aortic stenosis undergoing aortic valve replacement?
Hazard Ratio: 2.5 (95% CI 1.6–3.9)
p-value: p=<0.0001
Preoperative right ventricular dysfunction detected by CMR is a powerful independent predictor of late all-cause mortality in patients with severe aortic stenosis undergoing aortic valve replacement.
May identify unrecognized RV dysfunction in severe AS; leaves open its prognostic value before routine CMR adoption.
Background The right ventricle (RV) is relatively understudied and often not routinely assessed in aortic stenosis (AS). However, there are several potential reasons for its importance. RV function is sensitive to left-sided afterload changes which can result in pulmonary hypertension (PH) in severe AS. PH is also a recognised predictor of poor prognosis in AS, but RV afterload and function can be difficult to assess. Cardiovascular magnetic resonance (CMR) may reveal unrecognised RV dysfunction and simultaneously evaluate other prognostic markers in AS. Purpose To investigate preoperative RV function assessed by CMR in severe AS and its association with mortality after aortic valve replacement (AVR). Methods 674 severe AS patients listed for either surgical or percutaneous AVR at six cardiothoracic centres underwent preoperative CMR (for ventricular function, mass and scar) along with echocardiography for valve severity. Scans were core-lab analysed for LV and RV volumes, function and scar quantification. Eight patients were excluded due to inadequate RV image quality for a total of 666 patients finally included. All-cause mortality was tracked for a minimum of 2 years after AVR. Results 107 (16%) of severe AS undergoing invasive AVR had a RV ejection fraction (RVEF) <55%. CMR detected overt RV dysfunction (RVEF <50%) in 61 (9%) patients. During a median 3.6 years follow-up, 145 (22%) patients died. Baseline RV dysfunction was the most powerful predictor of all-cause mortality (hazard ratio [HR] 2.5, 95% CI 1.6–3.9, p<0.0001). RV function was independent from other clinical characteristics but associated with signs of LV maladaptation (LV ejection fraction [LVEF] and late gadolinium enhancement [LGE]). The strongest Cox multivariable model for all-cause mortality accounted for RV dysfunction, age and LGE (adjusted HRs 1.7, 1.1, 2.2, respectively). Even early stages of pre-procedural RV dysfunction (RVEF 45–50%) were associated with reduced long-term survival. Cox and Kaplan-Meier for all-cause death Conclusion One out of 6 patients with severe AS undergoing valve replacement manifests a reduction in RV function detectable by CMR. Those with RV dysfunction (RVEF<50%) have a 2.5-fold increase in all-cause mortality after AVR at 3.6 years. Whilst RV dysfunction is associated with LV maladaptation (LGE, LVEF), it is a powerful independent factor associated with all-cause mortality and impacts survival even at early stages. Thus, the RV appears to be important in cardiac adaptation to AS and longevity after AS intervention. Acknowledgement/Funding British Heart Foundation and National Institute of Health Research
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Rigolli et al. (2019) conducted a cohort in Severe aortic stenosis (n=666). Right ventricular dysfunction (RVEF <50%) vs. Normal right ventricular function was evaluated on All-cause mortality (HR 2.5, 95% CI 1.6-3.9, p=<0.0001). Preoperative right ventricular dysfunction (RVEF <50%) was associated with a 2.5-fold increase in all-cause mortality after aortic valve replacement (HR 2.5; 95% CI 1.6-3.9; p<0.0001).
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