title: Prognostic value of myocardial fibrosis in patients with severe aortic valve stenosis.
abstract: OBJECTIVE
  To evaluate whether myocardial fibrosis influences left ventricular performance in severe aortic stenosis and to assess its effect on long-term survival after aortic valve replacement.
  
  
  METHODS
  Myocardial fibrosis was evaluated in biopsy specimens taken from the interventricular septum in 99 patients undergoing aortic valve replacement because of severe or prevalent aortic stenosis. Clinical and echocardiographic evaluations were performed at a mean follow-up of 6.2 ± 3.0 years. The patients were classified according to the myocardial fibrosis severity (none or mild in 28, moderate in 52, and severe in 19).
  
  
  RESULTS
  Patients with severe myocardial fibrosis had a dilated left ventricle and positive association between the left ventricular end-diastolic diameter (R = 0.77, P < .001), left ventricular end-systolic diameter (R = 0.78, P < .001), left ventricular end-systolic wall stress (R = 0.74, P < .001) and the degree of myocardial fibrosis. Myocardial fibrosis was inversely related to left ventricular fractional shortening (R = -0.64, P < .001), left ventricular ejection fraction (R = -0.53, P < .001), and left ventricular relative wall thickness (R = -0.70, P < .001). Patients with a higher grade of myocardial fibrosis had a significantly lower freedom from cardiac death at 10 years (42% ± 19% vs 89% ± 6%, P = .002), with congestive heart failure the most common cause of death. At Cox regression analysis, patient age (P = .012), low preoperative transvalvular gradient less than 40 mm Hg (P = .040), preoperative end-systolic wall stress (P = .046), and preoperative myocardial fibrosis grade (P = .034) emerged as the strongest independent predictors of mortality.
  
  
  CONCLUSIONS
  In patients with severe aortic valve stenosis, the amount of myocardial fibrosis appears to have significant effect on clinical status and long-term survival after aortic valve replacement. From these results, we believe that new strategies for the earlier detection of myocardial fibrosis are needed to achieve a better prognostic outcome.
authors.affiliation: Division of Cardiac Surgery, University of Verona, Verona, Italy. aldo.milano@univr.it
authors.forename: Aldo Domenico
authors.initials: AD
authors.lastname: Milano
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Faggian
authors.forename: Mikhail
authors.initials: M
authors.lastname: Dodonov
authors.forename: Giorgio
authors.initials: G
authors.lastname: Golia
authors.forename: Anna
authors.initials: A
authors.lastname: Tomezzoli
authors.forename: Uberto
authors.initials: U
authors.lastname: Bortolotti
authors.forename: Alessandro
authors.initials: A
authors.lastname: Mazzucco
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001706:Biopsy; D016009:Chi-Square Distribution; D018572:Disease-Free Survival; D018619:Echocardiography, Doppler, Pulsed; D005260:Female; D005355:Fibrosis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D009206:Myocardium / Q000473:pathology*; D016016:Proportional Hazards Models; D020127:Recovery of Function; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000503:physiopathology*; D016277:Ventricular Function, Left; D054088:Ventricular Septum / Q000473:pathology*