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Jex N, Greenwood JP, Cubbon RM, Rider OJ, Chowdhary A, Thirunavukarasu S, Kotha S, Giannoudi M, McGrane A, Maccannell A, Conning-Rowland M, Straw S, Procter H, Papaspyros S, Evans B, Javangula K, Ferrara A, Elmahdy W, Kaul P, Xue H, Swoboda P, Kellman P, Valkovič L, Roberts L, Beech D, Kearney MT, Plein S, Dweck MR, Levelt E. Association Between Type 2 Diabetes and Changes in Myocardial Structure, Contractile Function, Energetics, and Blood Flow Before and After Aortic Valve Replacement in Patients With Severe Aortic Stenosis. Circulation 2023; 148:1138-1153. [PMID: 37746744 PMCID: PMC10558154 DOI: 10.1161/circulationaha.122.063444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 08/15/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Type 2 diabetes (T2D) is associated with an increased risk of left ventricular dysfunction after aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). Persistent impairments in myocardial energetics and myocardial blood flow (MBF) may underpin this observation. Using phosphorus magnetic resonance spectroscopy and cardiovascular magnetic resonance, this study tested the hypothesis that patients with severe AS and T2D (AS-T2D) would have impaired myocardial energetics as reflected by the phosphocreatine to ATP ratio (PCr/ATP) and vasodilator stress MBF compared with patients with AS without T2D (AS-noT2D), and that these differences would persist after AVR. METHODS Ninety-five patients with severe AS without coronary artery disease awaiting AVR (30 AS-T2D and 65 AS-noT2D) were recruited (mean, 71 years of age [95% CI, 69, 73]; 34 [37%] women). Thirty demographically matched healthy volunteers (HVs) and 30 patients with T2D without AS (T2D controls) were controls. One month before and 6 months after AVR, cardiac PCr/ATP, adenosine stress MBF, global longitudinal strain, NT-proBNP (N-terminal pro-B-type natriuretic peptide), and 6-minute walk distance were assessed in patients with AS. T2D controls underwent identical assessments at baseline and 6-month follow-up. HVs were assessed once and did not undergo 6-minute walk testing. RESULTS Compared with HVs, patients with AS (AS-T2D and AS-noT2D combined) showed impairment in PCr/ATP (mean [95% CI]; HVs, 2.15 [1.89, 2.34]; AS, 1.66 [1.56, 1.75]; P<0.0001) and vasodilator stress MBF (HVs, 2.11 mL min g [1.89, 2.34]; AS, 1.54 mL min g [1.41, 1.66]; P<0.0001) before AVR. Before AVR, within the AS group, patients with AS-T2D had worse PCr/ATP (AS-noT2D, 1.74 [1.62, 1.86]; AS-T2D, 1.44 [1.32, 1.56]; P=0.002) and vasodilator stress MBF (AS-noT2D, 1.67 mL min g [1.5, 1.84]; AS-T2D, 1.25 mL min g [1.22, 1.38]; P=0.001) compared with patients with AS-noT2D. Before AVR, patients with AS-T2D also had worse PCr/ATP (AS-T2D, 1.44 [1.30, 1.60]; T2D controls, 1.66 [1.56, 1.75]; P=0.04) and vasodilator stress MBF (AS-T2D, 1.25 mL min g [1.10, 1.41]; T2D controls, 1.54 mL min g [1.41, 1.66]; P=0.001) compared with T2D controls at baseline. After AVR, PCr/ATP normalized in patients with AS-noT2D, whereas patients with AS-T2D showed no improvements (AS-noT2D, 2.11 [1.79, 2.43]; AS-T2D, 1.30 [1.07, 1.53]; P=0.0006). Vasodilator stress MBF improved in both AS groups after AVR, but this remained lower in patients with AS-T2D (AS-noT2D, 1.80 mL min g [1.59, 2.0]; AS-T2D, 1.48 mL min g [1.29, 1.66]; P=0.03). There were no longer differences in PCr/ATP (AS-T2D, 1.44 [1.30, 1.60]; T2D controls, 1.51 [1.34, 1.53]; P=0.12) or vasodilator stress MBF (AS-T2D, 1.48 mL min g [1.29, 1.66]; T2D controls, 1.60 mL min g [1.34, 1.86]; P=0.82) between patients with AS-T2D after AVR and T2D controls at follow-up. Whereas global longitudinal strain, 6-minute walk distance, and NT-proBNP all improved after AVR in patients with AS-noT2D, no improvement in these assessments was observed in patients with AS-T2D. CONCLUSIONS Among patients with severe AS, those with T2D demonstrate persistent abnormalities in myocardial PCr/ATP, vasodilator stress MBF, and cardiac contractile function after AVR; AVR effectively normalizes myocardial PCr/ATP, vasodilator stress MBF, and cardiac contractile function in patients without T2D.
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Affiliation(s)
- Nicholas Jex
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - John P. Greenwood
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Richard M. Cubbon
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Oliver J. Rider
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), RDM Cardiovascular Medicine, University of Oxford, UK (O.J.R., L.V.)
| | - Amrit Chowdhary
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Sharmaine Thirunavukarasu
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Sindhoora Kotha
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Marilena Giannoudi
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Anna McGrane
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
| | - Amanda Maccannell
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
| | - Marcella Conning-Rowland
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
| | - Sam Straw
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Henry Procter
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Sotiris Papaspyros
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
| | - Betsy Evans
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Kalyana Javangula
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Antonella Ferrara
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Walid Elmahdy
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Pankaj Kaul
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Hui Xue
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD (H.X., P. Kellman)
| | - Peter Swoboda
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD (H.X., P. Kellman)
| | - Ladislav Valkovič
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), RDM Cardiovascular Medicine, University of Oxford, UK (O.J.R., L.V.)
- Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia (L.V.)
| | - Lee Roberts
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
| | - David Beech
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
| | - Mark T. Kearney
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Sven Plein
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Marc R. Dweck
- University of Edinburgh/BHF Centre for Cardiovascular Science, Edinburgh, UK (M.R.D.)
| | - Eylem Levelt
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
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