Comprehensive myocardial characterization using cardiac magnetic resonance associates with outcomes in low gradient severe aortic stenosis

Miho Fukui, Mohamed-Salah Annabi, Vitor E E Rosa, Henrique B Ribeiro, Larissa I Stanberry, Marie-Annick Clavel, Josep Rodés-Cabau, Flavio Tarasoutchi, Erik B Schelbert, Jutta Bergler-Klein, Philipp E Bartko, Carolina Dona, Julia Mascherbauer, Abdellaziz Dahou, Carlos E Rochitte, Philippe Pibarot, João L Cavalcante

Research output: Journal article (peer-reviewed)Journal article

9 Citations (Scopus)


AIMS: This study sought to compare cardiac magnetic resonance (CMR) characteristics according to different flow/gradient patterns of aortic stenosis (AS) and to evaluate their prognostic value in patients with low-gradient AS.

METHODS AND RESULTS: This international prospective multicentric study included 147 patients with low-gradient moderate to severe AS who underwent comprehensive CMR evaluation of left ventricular global longitudinal strain (LVGLS), extracellular volume fraction (ECV), and late gadolinium enhancement (LGE). All patients were classified as followings: classical low-flow low-gradient (LFLG) [mean gradient (MG) < 40 mmHg and left ventricular ejection fraction (LVEF) < 50%]; paradoxical LFLG [MG < 40 mmHg, LVEF ≥ 50%, and stroke volume index (SVi) < 35 ml/m2]; and normal-flow low-gradient (MG < 40 mmHg, LVEF ≥ 50%, and SVi ≥ 35 ml/m2). Patients with classical LFLG (n = 90) had more LV adverse remodelling including higher ECV, and higher LGE and volume, and worst LVGLS. Over a median follow-up of 2 years, 43 deaths and 48 composite outcomes of death or heart failure hospitalizations occurred. Risks of adverse events increased per tertile of LVGLS: hazard ratio (HR) = 1.50 [95% CI, 1.02-2.20]; P = 0.04 for mortality; HR = 1.45 [1.01-2.09]; P < 0.05 for composite outcome; per tertile of ECV, HR = 1.63 [1.07-2.49]; P = 0.02 for mortality; HR = 1.54 [1.02-2.33]; P = 0.04 for composite outcome. LGE presence also associated with higher mortality, HR = 2.27 [1.01-5.11]; P < 0.05 and composite outcome, HR = 3.00 [1.16-7.73]; P = 0.02. The risk of mortality and the composite outcome increased in proportion to the number of impaired components (i.e. LVGLS, ECV, and LGE) with multivariate adjustment.

CONCLUSIONS: In this international prospective multicentric study of low-gradient AS, comprehensive CMR assessment provides independent prognostic value that is cumulative and incremental to clinical and echocardiographic characteristics.

Original languageEnglish
Pages (from-to)46-58
Number of pages13
JournalEuropean Heart Journal Cardiovascular Imaging
Issue number1
Early online date25 May 2022
Publication statusPublished - 01 Jan 2023


  • Aortic Valve Stenosis
  • Contrast Media
  • Gadolinium
  • Humans
  • Magnetic Resonance Imaging, Cine/methods
  • Magnetic Resonance Spectroscopy
  • Prognosis
  • Prospective Studies
  • Stroke Volume
  • Ventricular Function, Left
  • extracellular volume fraction
  • global longitudinal strain
  • aortic stenosis
  • mortality
  • late gadolinium enhancement
  • cardiac magnetic resonance
  • low flow low gradient

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Radiology, Nuclear Medicine and Imaging


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