Cardiac MRI-derived extracellular volume fraction is associated with failed left ventricular reverse remodeling after aortic valve replacement in severe aortic regurgitation With a giant left ventricle

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Severe chronic aortic regurgitation with a giant left ventricle (LVEDD ≥65 mm) undergoing elective aortic valve replacement (n=46). Intervention: Preoperative CMR-derived extracellular volume fraction (ECV, per 1% absolute increase) vs. Lower preoperative ECV / ECV ≤34.1%. Primary outcome: Continuous relative change in left ventricular end-diastolic diameter (ΔLVEDD%) at 6 months after aortic valve replacement (β -0.924 per 1% absolute increase in ECV, 95% CI -1.528 to -0.320, p=0.004).

Q: What does this research mean for the field?

Higher preoperative cardiac magnetic resonance-derived extracellular volume fraction is associated with a lower degree of left ventricular reverse remodeling after aortic valve replacement in patients with severe aortic regurgitation and a giant left ventricle. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Hao Niu; Yangbo Yan; Xiangfeng Gong; Xiao Xiao; Changping Gan; ZhengHua Xiao

doi:10.3389/fcvm.2026.1943775

November 3, 2026Frontiers in Cardiovascular MedicineOpen Access

Cardiac MRI-derived extracellular volume fraction is associated with failed left ventricular reverse remodeling after aortic valve replacement in severe aortic regurgitation With a giant left ventricle

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Why the study?

Severe chronic AR with a giant LV carries a high risk of incomplete LV reverse remodeling after AVR, yet reliable preoperative stratification tools remain limited.

Is preoperative cardiac magnetic resonance-derived extracellular volume fraction (ECV) associated with 6-month left ventricular reverse remodeling after elective aortic valve replacement in patients with severe chronic aortic regurgitation and a giant left ventricle (LVEDD ≥65 mm)?

Key Points

To evaluate whether preoperative cardiac magnetic resonance (CMR)-derived extracellular volume fraction (ECV) is associated with 6-month left ventricular reverse remodeling after aortic valve replacement in patients with severe chronic aortic regurgitation and a giant left ventricle.
Retrospective cohort study of 46 consecutive patients with severe aortic regurgitation and left ventricular end-diastolic diameter (LVEDD) ≥65 mm undergoing contrast-enhanced 3.0 T CMR and elective aortic valve replacement.
Evaluated the continuous relative change in LVEDD at 6 months as the primary outcome, and a binary definition of failed reverse remodeling (<20% LVEDD reduction) as a secondary outcome.
Quantified native and post-contrast T1 mapping to calculate ECV in the mid-ventricular septum, analyzing associations using linear regression and multivariable logistic regression.
Failed left ventricular reverse remodeling (<20% LVEDD reduction) occurred in 47.8% (22/46) of patients at 6 months.
Higher preoperative ECV was significantly associated with smaller relative LVEDD reduction on continuous linear regression (β = -0.924 per 1% absolute increase in ECV, 95% CI -1.528 to -0.320, P = 0.004).
On multivariable logistic regression adjusting for baseline LVEDD, ECV was associated with failed reverse remodeling (adjusted OR = 1.281, 95% CI 1.001–1.640, P = 0.049), with an exploratory cutoff of 34.1% yielding an AUC of 0.74 (95% CI 0.59–0.89), though attenuation occurred after adjusting for age (OR 1.227, 95% CI 0.950–1.585, P = 0.117).

Study Design

Type

Cohort (n=46)

Blinding

Blinded outcome assessment (radiologists and echocardiographers blinded to clinical outcomes)

Multicenter

No

Structured PICO

Is preoperative cardiac magnetic resonance-derived extracellular volume fraction (ECV) associated with 6-month left ventricular reverse remodeling after elective aortic valve replacement in patients with severe chronic aortic regurgitation and a giant left ventricle (LVEDD ≥65 mm)?

P

Population

46 adults (mean age 50.8 years, 15.2% female) in China with severe chronic aortic regurgitation and a giant left ventricle (LVEDD ≥65 mm) undergoing preoperative contrast-enhanced CMR and elective aortic valve replacement, followed for 6 months.

E

Exposure

Preoperative contrast-enhanced 3.0 T cardiac magnetic resonance (CMR) with gadobenate dimeglumine (0.2 mmol/kg IV) to measure native and post-contrast T1 mapping and extracellular volume fraction (ECV), followed by elective surgical aortic valve replacement (AVR) via median sternotomy under cardiopulmonary bypass (isolated mechanical AVR n=9, isolated bioprosthetic AVR n=6, AVR plus tricuspid valvuloplasty n=2, AVR plus ascending aortoplasty n=7, Wheat procedure n=1, Bentall procedure n=21).

O

Outcome

Continuous relative change in left ventricular end-diastolic diameter at 6 months (ΔLVEDD%), calculated as [(LVEDD at 6 months − baseline LVEDD) / baseline LVEDD] × 100, measured by transthoracic echocardiography blinded to CMR findings and clinical outcomes.surrogate

Main Result

Effect estimate: β -0.924 per 1% absolute increase in ECV (95% CI -1.528 to -0.320)

p-value: p=0.004

Preoperative CMR-derived extracellular volume fraction is inversely associated with 6-month LV reverse remodeling after aortic valve replacement in patients with severe aortic regurgitation and a giant left ventricle, offering a potential non-invasive biomarker for preoperative risk stratification.

Limitations

Single-center retrospective design with a small sample size (46 patients analyzed)
Survivor bias due to exclusion of 4 patients who died or did not complete 6-month follow-up
Post hoc definition of the binary 20% LVEDD reduction secondary endpoint and exploratory ECV cutoff (34.1%)
Missing archival data for preoperative CMR ventricular volumes, aortic dimensions, and exact CMR-to-surgery time intervals
Inability to quantify echocardiographic intra- and inter-observer reproducibility or spatial LGE distribution
Single-center retrospective cohort design with a small sample size (n=46) and only 22 binary outcome events
Survivor bias due to restricting the primary analysis to survivors who completed the 6-month assessment (4 of 50 enrolled patients died or were discharged before the endpoint)
Post hoc definition of the 20% LVEDD reduction threshold for the binary secondary endpoint
Inability to quantify intra- and inter-observer reproducibility for echocardiography because original raw measurement datasets were no longer available
Missing data in retrospective records, including exact interval between CMR and surgery, spatial distribution of LGE, detailed non-bicuspid AR etiology, preoperative aortic dimensions, and CMR-derived ventricular volumes (LVEDV/LVESV)

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Implication

ECV may aid preoperative risk stratification in severe AR with giant LV; leaves open whether it guides AVR timing or improves outcomes.

Abstract

Severe chronic aortic regurgitation (AR) with a markedly dilated left ventricle (LV) (‘giant left ventricle’; LV end-diastolic diameter, LVEDD ≥65 mm) carries a high risk of incomplete LV reverse remodeling after aortic valve replacement (AVR), yet reliable preoperative stratification tools remain limited. This retrospective cohort study aimed to evaluate whether preoperative cardiac magnetic resonance (CMR)-derived extracellular volume fraction (ECV) is associated with 6-month LV reverse remodeling in this high-risk population. We enrolled 46 consecutive patients with severe AR and LVEDD ≥65 mm receiving contrast-enhanced CMR and elective AVR. The primary analysis assessed the association between preoperative ECV and the continuous relative change in LVEDD at 6 months; a binary definition (≥20% LVEDD reduction) was used as a secondary, clinically oriented outcome. Absence of significant LV reverse remodeling (<20% reduction) was observed in 47.8% (22/46) of patients. In linear regression analysis, higher preoperative ECV was significantly associated with a smaller LVEDD reduction ( β = −0.924 per 1% absolute increase in ECV, 95% CI −1.528 to −0.320, P = 0.004). In multivariable logistic regression restricted to the preoperative variables significant on univariable analysis (ECV and LVEDD), ECV remained associated with failed reverse remodeling (adjusted OR = 1.281 per 1% absolute increase in ECV, 95% CI 1.001–1.640, P = 0.049), although the association attenuated after further adjustment for age (OR 1.227, 95% CI 0.950–1.585, P = 0.117); with an exploratory cutoff of 34.1% (AUC=0.74, 95%CI 0.59–0.89). Patients with ECV >34.1% exhibited impaired postoperative LV systolic function and prolonged hospital stay. These exploratory findings suggest that preoperative CMR-ECV may help identify severe AR patients at risk of incomplete LV reverse remodeling after AVR, and warrant prospective validation.

Discussion

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Cite This Study

Niu et al. (2026) conducted a cohort in Severe chronic aortic regurgitation with a giant left ventricle (LVEDD ≥65 mm) undergoing elective aortic valve replacement (n=46). Preoperative CMR-derived extracellular volume fraction (ECV, per 1% absolute increase) vs. Lower preoperative ECV / ECV ≤34.1% was evaluated on Continuous relative change in left ventricular end-diastolic diameter (ΔLVEDD%) at 6 months after aortic valve replacement (β -0.924 per 1% absolute increase in ECV, 95% CI -1.528 to -0.320, p=0.004).

synapsesocial.com/papers/6aebc8cf3e63ca1b6c315ed4 https://doi.org/10.3389/fcvm.2026.1943775

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Cardiac MRI-derived extracellular volume fraction is associated with failed left ventricular reverse remodeling after aortic valve replacement in severe aortic regurgitation With a giant left ventricle

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Cardiac MRI-derived extracellular volume fraction is associated with failed left ventricular reverse remodeling after aortic valve replacement in severe aortic regurgitation With a giant left ventricle

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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