Preoperative CMR Scar Predicts Incomplete Reverse Remodeling After AVR: JAMA

A new study published in the Journal of American Medical Association showed that at seven months, aortic valve replacement (AVR) significantly reversed cardiac remodeling in patients with chronic aortic regurgitation, including a decrease in indexed extracellular volume and a regression of myocardial hypertrophy.

Chronic aortic regurgitation produces chronic left ventricular volume overload, which results in ventricular dilation, hypertrophy, and progressive myocardial fibrosis. Although valve replacement reduces hemodynamic stress and promotes reverse remodeling, the amount and reversibility of myocardial fibrosis may impact recovery. Understanding these alterations is critical for determining optimal surgical scheduling and predicting long-term results. This study sought to measure reverse remodeling, functional recovery, and symptomatic change following AVR, as well as determine if myocardial fibrosis is related to inadequate recovery.

Patients with chronic severe AR who were recommended for AVR by a cardiology team were enrolled in this prospective long-term observational research. Other main cardiomyopathies, moderate or severe valve dysfunction, and prior valve surgery were important exclusion factors. Cardiovascular magnetic resonance imaging (CMR), echocardiography, cardiopulmonary exercise testing, and matched biomarkers were performed on the included patients at baseline and a median of seven months following AVR.

Enrollment for the trial ran from August 2021 to October 2023 at two tertiary cardiothoracic facilities in London, United Kingdom. Data analysis took place between January and April of 2026. With a predetermined focus on CMR fibrosis indicators (late gadolinium enhancement [LGE] and extracellular volume [ECV]), the primary objectives were left ventricular (LV) reverse remodeling (change in LV end-diastolic volume [LVEDV] and LV mass) post-AVR and preoperative predictors of partial recovery.

Aortic regurgitant volume, LV end-diastolic volume (LVEDV), and LV mass all significantly reduced by 92%, 44%, and 21% among 72 patients (all *P*<.001). While the ECV percentage rose, indexed intracellular and extracellular volumes similarly decreased.

Higher baseline LGE was linked to lower LV mass and LVEDV regression, although LGE load did not alter. Peak oxygen consumption did not vary, but NYHA class and quality of life did. While NT-proBNP levels considerably dropped in individuals with signs of decompensation, there was no discernible overall decline.

Overall, AVR was linked with significant reverse remodeling at 7 months, including hypertrophic regression and a decrease in indexed extracellular (matrix) volume; nevertheless, the extracellular volume percentage increased as cellular regression outpaced matrix regression.

Source:

Thornton, G. D., Bennett, J. B., Aziminia, N., Tapia, L., Birkinshaw, A., McKenna, M., Pierce, I., Batay, M., Generoso, J., Bhattacharyya, S., Lloyd, G., Sado, D., Kellman, P., González, A., Moon, J. C., Treibel, T. A., & Barts Valve Team Investigators. (2026). Myocardial fibrosis and reverse remodeling after valve replacement in chronic aortic regurgitation. JAMA Cardiology. https://doi.org/10.1001/jamacardio.2026.3204