1. British Society of Cardiovascular Magnetic Resonance
Late-Breaking Registry Results
Aortic valve disease
BSCMR AS700
Scar Predicts Mortality in Aortic Stenosis
Myocardial Scar Predicts Mortality in Severe Aortic Stenosis: Data from the BSCMR Valve Consortium
British Society of Cardiovascular Magnetic Resonance
Thomas Treibel, Tarique Musa, Vass Vassiliou, Gabriella Captur, Anvesha Singh, Calvin Chin, Margaret Loudon, Marcia Rigolli, Laura Dobson, Silvia Pica, Tamir Malley, James Foley, Petra Bjisterveld, Graham Law, Mark Dweck, Saul Myerson, Gerry McCann, Sanjay Prassad, James Moon, John Greenwood

2. Background – Aortic Stenosis
Most common cardiovascular disease after atherosclerosis and hypertension
Intervention improves survival 1,2
Risk stratification and timing of intervention is primarily based on 1,2
severity of the stenosis
symptom onset
impaired LV function
1Vahanian A, et al. EHJ 2012; 33(19):
2Nishimura RA et al. JACC 2017 Jul 11;70(2):

3. Background – Challenges
Symptoms can be difficult to elucidate
LV systolic dysfunction occurs late
Risk: Awaiting intervention
- Residual, post intervention (irreversible changes)
Objective and early markers of cardiac decompensation needed
Heart failure
Arrhythmia
Death

4. Background – Myocardial Scar
Key to transition from hypertrophy to heart failure 1
CMR detects fibrosis using late gadolinium enhancement (LGE)
Single-centre studies:
Fibrosis associated with LV decompensation and adverse clinical outcomes 2,3,4
1Weidemann et. al. Circulation 2009; 120(7):
2Azevedo et. al. JACC 2010; 56(4):
3Dweck et. al. JACC 2011; 58(12):
4Barone-Rochette et. al. JACC 2014; 64(2):

5. Hypothesis
Hypertrophy
Dilatation
Impairment
Scar
Parameters of left ventricular adaptation are incremental predictors of mortality after valve intervention in aortic stenosis
The aim of this study was to determine pre-operative factors associated with late mortality in patients with severe AS on conventional management pathways, which could potentially be used to time surgery better in the future.
“A longitudinal study of the prognostic valve of imaging parameters in patients with severe AS at six UK centres who had been both scheduled for aortic valve intervention and who had been prospectively recruited, consented and completed a research pre-intervention CMR scan”

6. Study Design Longitudinal, observational outcome study
Edinburgh
Leeds
Leicester
Oxford
London
(UCL, Imperial)
Longitudinal, observational outcome study
Patients with severe AS 1
Listed for valve intervention (SAVR or TAVI)2
Prospectively recruited after Heart Team evaluation
Echocardiography and CMR as part of work-up
Prognostic value of derived imaging parameters
Primary endpoint: All-cause mortality
Secondary endpoint: Cardiovascular mortality
Six UK surgical centres between January 2003 and May 2015
2Exclusion criteria: pregnancy/breastfeeding, estimated GFR <30mL/min/1·73m2, CMR non-conditional devices.
A longitudinal, observational outcome study in patients with severe AS referred to six UK cardiothoracic surgical centres and listed for valve intervention
(Brompton Hospital and Barts Heart Centre in London; Edinburgh Heart Centre; Glenfield Hospital in Leicester; Leeds Teaching Hospitals NHS Trust; John Radcliffe Hospital in Oxford).
Between January 2003 and May 2015, patients were prospectively recruited after evaluation by the multi-disciplinary heart team.

7. AS700 British Society of Cardiovascular Magnetic Resonance Residual Risk after Intervention in Aortic Stenosis
Multi-centre, multi-modality study in severe aortic stenosis (n=703)
High mortality (24% at median 3.6 years)
Scar doubles mortality.
all-cause (28·7% vs 14·5%; p<0·001) and
cardiovascular mortality (16·6% vs 6·4%; p<0·001)
Regardless of aetiology (infarct or non) or intervention
Sole independent predictors of all-cause mortality:
Age (HR 1·07, p<0.001)
Scar presence (HR 2·13, p=0·003)
Female sex (HR 1·69, p=0.018)
1% increase scar burden
10% increased all-cause mortality
9% increased cardiovascular mortality
Myocardial Scar Predicts Mortality in Severe Aortic Stenosis: Data from the BSCMR Valve Consortium
Thomas Treibel, Tarique Musa, Vass Vassiliou, Gabriella Captur, Anvesha Singh, Calvin Chin, Margaret Loudon, Marcia Rigolli, Laura Dobson, Silvia Pica, Tamir Malley, James Foley, Petra Bjisterveld, Graham Law, Mark Dweck, Saul Myerson, Gerry McCann, Sanjay Prassad, James Moon, John Greenwood
SUMMARY SLIDE

8. Conclusion – in severe Aortic Stenosis
Significant mortality at 3.6 years = 24%
Myocardial scar is a key outcome predictor
Present in 51%
Doubles mortality
1% in scar = 10% in mortality
Strongest independent predictor of all-cause and cardiovascular mortality
Timing valve intervention to pre-empt scar development or progression now warrants clinical trial investigation.