Cardiac MRI Derived Strain Predicts LV Recovery in Pediatric and Young Adult Patients Undergoing Aortic Valve Intervention for Significant Regurgitation

Background: The management of pediatric and young adults with pure aortic valve regurgitation (AR) remains challenging and controversial. Traditionally, children and young adults are treated conservatively, with deferment until there is evidence of symptoms, left ventricle (LV) systolic dysfunction, and progressive LV enlargement. Current adult guidelines indicate that earlier intervention with aortic valve replacement (AVR) before the development of LV systolic dysfunction ((LVEF ≤ 50%) or severe dilation (LVESD > 50 mm, indexed LVESD > 25mm/m², or LVEDD >65 or 70mm) is associated with improved mortality and morbidity rates^1,2. Unfortunately, when these adult criteria have been applied to pediatric and young adult populations with AR, normalization of the LV following surgery is not always achieved³. As a result, the optimal timing of AVR in the pediatric and young adult population remains unknown. We sought to evaluate preoperative magnetic resonance (CMR) and echocardiogram parameters as predictors of LV recovery in pediatric and young adult patients undergoing aortic valve intervention for AR.

Methods: Using our data base we identified patients less than 30 years of age with primary diagnosis of AR who underwent aortic valve intervention at our institution from October 2020 to December 2024. A retrospective chart review was performed. Preoperative echocardiograms and CMR’s were reviewed and then compared to 6-12 month postoperative studies. Preoperative predictors of LV recovery were identified by a logistic regression model.

Results: A total of 22 participants (males 91%) were identified whom had both imaging before and after to allow analysis. In majority of patients the original aortic valve morphology was bicuspid (73%). Before undergoing AVR, 68% of patients had undergone at least one intervention. Most common previous intervention was transcatheter balloon valvuloplasty (55%). The mean age at time of aortic valve intervention was 16 years (Range 2-30 years). Type of aortic valve interventions performed included aortic valve repair (36%), mechanical replacement (32%), Ross procedure (27%) and bioprosthetic replacement (4.5%). At follow up, 91% of the cohort had improvement in LV size compared to preoperative parameters but only 55% had complete LV recovery based on normalization of LV volumes and systolic function. Based on the analysis, the strongest predictor of LV recovery for the cohort was preoperative CMR derived strain parameters.

Conclusion: In our series, the majority of pediatric and young adult patients who underwent aortic valve intervention for AR showed evidence of improvement in LV dimensions and function at last follow-up. Full LV recovery based on normalization of LV dimensions and function, however, occurred in just over half with the strongest predictor of LV recovery being preoperative strain parameters. Further studies are needed to confirm our result, but CMR derived strain may be a useful parameter for predicting LV recovery.