| Background: Aortic valve disease(AVD)mainly includes aortic stenosis(AS)and aortic regurgitation(AR).Severe AVD features progressive accumulation of interstitial myocardial fibrosis(MF)and myocyte degeneration,which may contribute to heart failure and various cardiac adverse events.It is reported that both the degree of myocyte degeneration and the amount of MF are inversely proportional to left ventricular function,assessing MF burden may predict outcomes in patients with AVD.Cardiovascular magnetic resonance(CMR)imaging is currently the only imaging approach that offers a direct and whole-heart assessment of MF,as a powerful tool for the diagnosis and risk stratification of AVD.CMR can visualize MF vividly with late gadolinium enhancement(LGE)that has been shown to be a marker of adverse outcomes in severe AS.However,previous studies have been limited to small sample sizes and found different results.In this study,a systematic review and meta-analysis of published studies was conducted to evaluate the predictive value of CMR-LGE in patients with severe AVD.Methods: PubMed,EMBASE,and Web of Science were searched for studies applying CMR-LGE to assess prognostic significance in patients with severe AVD and to measure MF.Screening for study eligibility and relevance of the articles retrieved was performed using the pre-defined inclusion criteria: 1)All the studies were cohort studies,including prospective and retrospective studies;2)MRI was used to evaluate MF in patients diagnosed with AVD in accordance with standard clinical guidelines;3)The study used LGE to quantify the MF and compared different outcomes between patients with and without MF.Studies were excluded: 1)the patients had other forms of VAD(mitral regurgitation or mitral stenosis);2)the patient numbers of both the LGE(+)and LGE(-)groups could not be extracted from the studies;3)there was no exact length of follow-up or a description of the main relevant features of the patients;4)patients underwent other treatment(such as Ross or Bentall procedures);or 5)the articles were abstracts,case reports,reviews,or editorial materials.The modified Newcastle-Ottawa scale(NOS,cohort version)was used to evaluate the quality of included prospective studies.The primary endpoints were all-cause mortality and cardiovascular mortality.The association of LGE with outcomes was estimated for each study by an odds ratio(OR)along with its 95% confidence interval(CI).Heterogeneity test showed a lack of significant heterogeneity for the chosen endpoints.Hence,a Mantel-Haenszel fixed-effects model was chosen to calculate the combined OR for each study.Besides,a modified Galbraith plot with missing study analysis and Harbord’s modified test were performed to determine publication bias.Statistical analysis was performed with Stata(version 15.1;Stata,College Station,TX,USA).Results: Six studies including 626 patients were included in the meta-analysis.The follow up period was from 0.5 to 5.7 years.These studies covered a wide spectrum of patients with AS,with a mean LVEF(%)ranging from 51 to 67,patients in the majority of studies had a history of coronary artery disease(CAD).The pooled OR was 3.28(95% CI: 2.02-5.32;p < 0.001)for LGE(+)versus LGE(-)in predicting patients with AVD in all-cause mortality.The presence of LGE was associated with cardiovascular mortality(pooled OR: 3.10,95% CI: 1.73-5.56;p < 0.001).The presence of LGE was associated with all-cause mortality in patients with severe AS after aortic valve replacement(AVR)(pooled OR: 2.30,95% CI: 1.06-4.99;p = 0.036).The result of Harbord’s test showed no publication bias among the individual studies(p = 0.365)and the modified Galbraith plot showed that the studies were distributed closely and symmetrically within the regression line.Conclusion: LGE on CMR is a promising risk stratification method,as it could predict all-cause mortality and cardiovascular mortality in patients with AVD,especially for AS.CMR-LGE also has significant prognostic value in patients after AVR. |
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