In patients with severe aortic stenosis undergoing aortic valve replacement, myocardial fibrosis is a strong predictor of mortality in both men and women, despite women having lower levels of late gadolinium enhancement. Aortic stenosis is a progressive condition that leads to left ventricular remodelling and myocardial fibrosis, which is associated with worse clinical outcomes. While previous research has suggested sex differences in fibrosis patterns, the prognostic impact of these differences in women with aortic stenosis remains unclear. Understanding whether myocardial fibrosis influences post-surgical outcomes differently between men and women could help refine risk stratification and treatment strategies in clinical practice.
This study prospectively enrolled 822 patients with severe aortic stenosis who underwent cardiovascular magnetic resonance imaging before aortic valve replacement. Among them, 670 patients (368 men and 302 women) had no obstructive coronary artery disease and were included in the primary analysis. Myocardial fibrosis was assessed using extracellular volume fraction and late gadolinium enhancement. Women and men had similar levels of extracellular volume fraction, but women had significantly lower late gadolinium enhancement, including both infarct and non-infarct patterns. Over a median follow-up of 3.7 years, 76 patients (11.3%) died, including 29 from cardiovascular causes. Cox regression analysis showed that increasing extracellular volume fraction was associated with a higher risk of all-cause mortality in women (hazard ratio [HR]: 1.08 per 1% increase; 95% CI: 1.04–1.12; P<0.001), whereas the association was not significant in men (HR: 1.01; 95% CI: 0.96–1.06; P=0.66). The presence of late gadolinium enhancement increased all-cause mortality risk in both sexes (HR: 2.49 in women and 1.82 in men), with no significant interaction by sex.
These findings highlight the prognostic value of myocardial fibrosis in both men and women with severe aortic stenosis undergoing valve replacement, reinforcing the need for fibrosis assessment in clinical decision-making. Despite lower late gadolinium enhancement, women remain at similar risk, suggesting fibrosis mechanisms may differ between sexes.
Jenna Lorge, EMJ
Reference
Kwak S et al. Sex-specific association of myocardial fibrosis with mortality in patients with aortic stenosis. JAMA Cardiol. 2025;DOI:10.1001/jamacardio.2024.55.
