The Role of Left Atrial Fibrosis in Mitral Valve Repair Surgery (ALIVE Trial)
Conditions: Mitral Valve Disease, Mitral Regurgitation, Surgery, Cardiac Valve Disease, Mitral Valve Surgery, Mitral Valve Repair
Sponsor: Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)

NL78497.018.21 / The role of left atrial fibrosis in mitral valve repair surgery (ALIVE study) 
 
 
 
 
 
 
 
 
 
 
 
 
 
The role of left atrial fibrosis in mitral 
valve repair surgery (ALIVE study) 
(Version 3.0, December 2021) 
 
 
 
 
 

NL78497.018.21 / The role of left atrial fibrosis in mitral valve repair surgery (ALIVE study) 
 
 
 
Title:  
The role of left atrial fibrosis in mitral valve repair surgery (ALIVE study) 
 
Protocol ID 
NL78497.018.21 
Short title 
Left atrial fibrosis in mitral valve repair candidates 
Version 
V3.0 
Date 
08-12-2021 
Principal investigator 
J. Kluin, MD PhD 
Cardiothoracic Surgeon, Department of Cardiothoracic 
Surgery 
Coordinating investigator 
M.J.W. Götte, MD PhD 
Cardiologist, Department of Cardiology 
Investigators 
J. Kluin, MD PhD 
Cardiothoracic Surgeon, Department of Cardiothoracic 
Surgery  
 
M.J.W. Götte, MD PhD 
Cardiologist, Department of Cardiology 
 
A.J. Nederveen, PhD 
MRI Physicist, Department of Radiology 
 
S. el Mathari, MD 
PhD Candidate, Department of Cardiothoracic Surgery 
Subsidising party 
Amsterdam UMC Scholarship 2020 
Independent expert 
M. Vervloet, MD PhD 
Nephrologist, Department of Internal Medicine 
 
 
 
 

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PROTOCOL SIGNATURE SHEET – Version 3.0 (December 2021) 
 
Name 
Signature 
Date 
Head of Department: 
R.J.M. Klautz, MD PhD 
Cardiothoracic Surgeon, Department 
of Cardiothoracic Surgery 
 
 
18-11-2021 
Principal Investigator: 
J. Kluin, MD PhD 
Cardiothoracic Surgeon, Department 
of Cardiothoracic Surgery 
 
17-11-2021 
Coordinating Investigator: 
M.J.W. Götte, MD PhD 
Cardiologist, Department of 
Cardiology 
 
18-11-2021 
Investigator: 
A.J. Nederveen, PhD 
MRI Physicist, Department of 
Radiology 
 
 
17-11-2021 
Investigator: 
S. el Mathari, MD 
PhD Candidate, Department of 
Cardiothoracic Surgery 
          
       
19-11-2021 
 
 

NL78497.018.21 / The role of left atrial fibrosis in mitral valve repair surgery (ALIVE study) 
 
 
 
TABLE OF CONTENTS 
 
1. 
INTRODUCTION AND RATIONALE .............................................................................. 8 
2. 
OBJECTIVES ................................................................................................................10 
3. 
STUDY DESIGN ...........................................................................................................11 
4. 
STUDY POPULATION ..................................................................................................14 
4.1 
Population (base) ...................................................................................................14 
4.2 
Inclusion criteria .....................................................................................................14 
4.3 
Exclusion criteria ....................................................................................................14 
4.4 
Sample size calculation ..........................................................................................15 
5. 
METHODS ....................................................................................................................16 
5.1 
Study parameters/endpoints ...................................................................................16 
5.1.1 
Main study parameter/endpoint .......................................................................16 
5.1.2 
Secondary study parameters/endpoints ..........................................................16 
5.1.3 
Other study parameters ...................................................................................16 
5.2 
Study procedures ...................................................................................................16 
5.3 
Withdrawal of individual subjects ............................................................................20 
5.4 
Replacement of individual subjects after withdrawal ...............................................20 
5.5 
Follow-up of subjects withdrawn from treatment .....................................................20 
5.6 
Premature termination of the study .........................................................................20 
6. 
SAFETY REPORTING ..................................................................................................20 
6.1 
Temporary halt for reasons of subject safety ..........................................................20 
6.2 
AEs and SAEs ........................................................................................................21 
6.2.1 
Adverse events (AEs) ......................................................................................21 
6.2.2 
Serious adverse events (SAEs) .......................................................................21 
6.3 
Follow-up of adverse events ...................................................................................22 
7. 
STATISTICAL ANALYSIS .............................................................................................23 
7.1 
Primary study parameters ......................................................................................23 
7.2 
Secondary study parameter ...................................................................................23 
7.3 
Other study parameters ..........................................................................................23 
8. 
ETHICAL CONSIDERATIONS ......................................................................................24 
8.1 
Regulation statement .............................................................................................24 
8.2 
Recruitment and consent........................................................................................24 
8.3 
Benefits and risks assessment, group relatedness .................................................24 
8.4 
Compensation for injury .........................................................................................25 
8.5 
Incentives ...............................................................................................................25 
9. 
ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION .............................26 
9.1 
Handling and storage of data and documents ........................................................26 
9.2 
Amendments ..........................................................................................................26 
9.3 
Annual progress report ...........................................................................................26 
9.4 
Temporary halt and (prematurely) end of study report ............................................27 
9.5 
Public disclosure and publication policy ..................................................................27 
10. 
REFERENCES ..........................................................................................................28 

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LIST OF ABBREVIATIONS AND RELEVANT DEFINITIONS  
 
3D 
Three Dimensional 
AE 
Adverse Event 
AF 
Atrial Fibrillation 
AR 
Adverse Reaction 
CMR(I) 
Cardiovascular Magnetic Resonance Imaging 
CV 
Curriculum Vitae 
ECV 
Extra Cellular Volume 
HF 
Heart Failure 
IC 
Informed Consent 
LA 
LGE 
Left Atrial 
Late Gadolinium Enhancement 
LV 
LVEF 
Left Ventricular 
Left Ventricular Ejection Fraction 
METC  
Medical research ethics committee (MREC); in Dutch: medisch-ethische 
toetsingscommissie (METC) 
MVI 
Mitral Valve Insufficiency 
PC-
MRA 
Phase Contrast Magnetic Resonance Angiography 
PH 
Pulmonary Hypertension 
(S)AE 
(Serious) Adverse Event  
WMO 
Medical Research Involving Human Subjects Act; in Dutch: Wet Medisch-
wetenschappelijk Onderzoek met Mensen 
 
 

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SUMMARY 
Rationale: Patients with mitral valve insufficiency (MVI) suffer from left atrial (LA) remodeling. 
Atrial fibrosis is part of this remodeling process. The presence of atrial fibrosis is associated 
with an increased risk of atrial fibrillation (AF), heart failure (HF), pulmonary hypertension (PH), 
a reduced quality of life and eventually a shorter life expectancy. 
 
Currently, mitral valve repair surgery is the ultimate treatment for severe primary MVI. The 
main indications and timing for surgery are severe MVI with symptoms or left ventricular 
dysfunction. However, the role of atrial fibrosis in this process remains undetermined despite 
its well-recognized clinical implications.  
Characterization of atrial fibrosis patterns in MVI patients might be potentially valuable for the 
indication and timing of mitral valve repair surgery in order to improve clinical outcomes.  
 
With the introduction of cardiac MRI for the assessment of atrial fibrosis in AF patients suffering 
from extensive LA remodeling without MVI, the identification of appropriate patients and 
therapy stratification for cardiac ablation and the associated clinical outcome was significantly 
improved. 
 
To date, however, MVI patients suffering from LA remodeling have hardly been studied using 
these new imaging techniques. Therefore, we intend to combine advanced cardiac MRI and 
post-processing techniques prior to and after mitral valve repair surgery to gain more insight 
in the clinical implications of atrial fibrosis in this patient population. 
 
It is hypothesized that the atrial fibrosis surface area paradoxically will increase after mitral 
valve surgery because of global shrinkage of the LA caused by the reversed remodeling 
process.[1] As a consequence, more frequently atrial fibrosis related events including 
(paroxysmal) AF, may be observed in these patients.  
 
Objective: To assess the effects of (reduced) volume overload on the left atrial wall texture 
(presence, amount and location of atrial fibrosis) and associated geometry and function in 
patients with MVI, prior to and after mitral valve repair surgery. 
 
Study design: Single center pilot study. 
 
 
 

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Study population: The research population consists of MVI patients scheduled for elective 
surgical mitral valve repair (N=20) according to the current European guideline criteria.  
 
Image data from non-MVI/AF age-sex matched controls (N=10), retrieved from an existing 
database will be used for reference purposes. These controls have undergone the same MRI 
scan protocol for another indication.  
 
Main study parameters/endpoints:  
The main study parameters are:  
1. Severity of MVI prior to and after surgery (defined as regurgitation volume in ml) 
2. Left atrial remodelling prior to and after surgery 
o Left atrial volume 
o Calculated left atrial sphericity 
o Estimated wall tension (wall thickness, radius, pulmonary wedge pressure) 
o Mitral regurgitation flow measurement (quantitative) 
3. Presence and distribution patterns of LA fibrosis  
o Quantification of fibrosis surface (severity) 
o Geometric distribution of fibrosis (localization) 
4. Blood flow patterns in the left atrium (4D flow) 
o Flow velocity (mean and peak) 
o Static fraction 
o Kinetic energy 
 
Nature and extent of the burden and risks associated with participation, benefit and 
group relatedness:  
This is a cardiac MRI study with the use of contrast media (Gadolinium).There is no associated 
additional risk expected for participating patients. There are no direct benefits for individuals 
participating to our study. 

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1. INTRODUCTION AND RATIONALE 
 
Patients with mitral valve insufficiency (MVI) frequently suffer from left atrial (LA) remodeling, 
caused by volume overload and subsequent atrial dilatation.[1] 
 
The associated myocardial stretch and increased wall tension, trigger a cascade of pathways 
leading to the occurrence of atrial fibrosis as part of the remodeling process (Figure 1).[2] The 
clinical relevance of this atrial fibrosis, is that its presence is associated with an increased risk 
of atrial fibrillation (AF), heart failure (HF), pulmonary hypertension (PH), a reduced quality of 
life and eventually a shorter life expectancy.[3, 4] In addition, in patients suffering from atrial 
fibrillation (AF), the presence and amount of LA fibrosis was found to be a strong predictor for 
ablation efficacy and long-term outcome.[5, 6] 
 
In daily clinical practice, MVI is managed either by medical or surgical therapy.[7] However, 
since medical therapy is often not sufficient for patients with severe primary MVI, surgical 
intervention remains the ultimate treatment option for these patients. In general, valve repair 
is the preferred type of surgery, since it has better clinical results compared to valve 
replacement.[8] 
Currently, the indication and timing for valve surgery is mainly based on the severity of  MVI 
and the presence of  symptoms and/or severity of left ventricular dysfunction.[9]  
 
For clinical decision making and patient stratification for mitral valve surgery, the presence of 
atrial fibrosis is currently not taken in account, despite its well-recognized clinical implications. 
 
Detection of atrial fibrosis patterns in patients with severe MVI, however, may be potentially 
valuable for the indication and timing of mitral valve repair surgery to improve clinical 
outcomes. Improved insight into atrial fibrosis patterns and changes after mitral valve repair 
due to reverse remodeling, may help clinicians in their clinical decision making and timing for 
surgery.  
 
Today, quantification of atrial fibrosis can be routinely performed using cardiac magnetic 
resonance imaging (CMR) techniques and advanced post-processing tools, offering non-
invasive tissue characterization in thin-walled structures.[6]  
 
To date, MVI patients suffering from LA remodeling have hardly been studied using these new 
imaging techniques. Therefore, in this study, we want to combine advanced cardiac MRI and 

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post-processing techniques prior to and after mitral valve repair surgery to gain insight on the 
clinical role and predictive value of atrial fibrosis in this patient population.  
 
In addition, we aim to assess the effects of (reduced) volume overload on atrial wall texture, 
geometry and function. 
 
It is hypothesized that the atrial fibrosis surface area paradoxically will increase after mitral 
valve surgery because of global shrinkage of the LA caused by the reversed remodeling 
process.[1] As a consequence, more frequently atrial fibrosis related events including 
(paroxysmal) AF, may be observed in these patients.  
 
With this insight, CMR can become clinical valuable for the indication and timing of surgical 
intervention in these patients. Surgical therapy might be renounced for example when a 
substantial increase of fibrosis surface is expected post-surgically causing a higher risk for AF, 
HF, PH and a reduced quality of life. On the contrary, surgical therapy might be considered in 
an earlier stage of disease when the amount of fibrosis is still limited regarding its expected 
post-surgical development. 
 
Figure 1. Pathway to structural LA remodeling caused by a pathological trigger. 
 
 
 

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2. OBJECTIVES 
 
Primary Objective:  
To assess  
- 
the effects of (reduced) volume overload on the left atrial wall texture (presence, 
amount and location of atrial fibrosis) and associated geometry and function in patients 
with MVI, prior to and after elective mitral valve repair surgery. 
 
Secondary Objectives: 
To assess; 
- 
the value of LA fibrosis in stratification and timing of mitral valve repair surgery. 
- 
the impact of atrial fibrosis on myocyte contractile function (atrial strain, quantified by 
CMR). 
- 
whether left ventricular (LV) volume overload results in increased extra cellular volume 
(ECV) and whether this is reversible after mitral valve repair surgery. 
- 
the impact of LA remodeling on right atrial (RA) function and tissue characteristics. 
- 
the predictive value of LA fibrosis for outcomes of AF and atrial function during post-
surgical follow up 
 
 
 
 

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3. STUDY DESIGN 
 
This study is designed as a single center pilot study. The aim of this study is to assess the role 
of left atrial fibrosis and its characteristics prior to and after mitral valve repair surgery in MVI 
patients. 
 
Study subjects that will be included are MVI patients who meet the criteria for mitral valve 
repair surgery and are on the waiting list for elective surgery. Exclusion criteria are: AF, history 
of cardiac surgery, comorbidities, MRI contra-indications. The study subjects are recruited from 
the Amsterdam UMC surgical waiting list. 
 
The study subjects will visit the AmsterdamUMC hospital (Location VUmc) two weeks prior to 
mitral valve repair surgery for a CMR scan. This visit will start with checking in- and exclusion 
criteria using questionnaires regarding medical history and MRI safety. The total duration of 
the visit, including the CMR scan, will be approximately two hours. 
 
Two weeks later the subjects will undergo mitral valve repair surgery (Location AMC). During 
anesthesia, a Swan-Ganz catheter will be used for hemodynamic monitoring. This Swan-Ganz 
catheter is part of the standard care for mitral valve repair surgery.  
 
At three months follow-up, subjects will visit the AmsterdamUMC hospital (Location VUmc) for 
a second CMR scan to assess reversed atrial remodeling and amount of fibrosis.  
 
Image date from age and gender matched controls will be retrieved from an existing 
database. The patients in this database have undergone the same MRI scan protocol (for a 
different medical indication) as scheduled for our study population. Only data from patients 
without MVI and AF will be used from the database for reference. Absence of MVI and AF 
will be confirmed by checking ECGs and echocardiography of the control patients.  
 
See figure 2 for a schematic representation of the study design. 

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Figure 2. Schematic representation of the study design: Left atrial remodeling in MVI

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4. STUDY POPULATION 
4.1 Population (base)  
The research population consists of MVI patients scheduled for elective surgical mitral valve 
repair conform the current guideline criteria. 
 
These patients will be recruited from the surgery-waiting list  / database of the AUMC after they 
have been accepted for surgery by a multidisciplinary heart team. 
 
Data from a control group of non-MVI/AF age-sex matched controls (N=10) will be retrieved 
from an existing database. These controls have undergone the same MRI scan protocol for a 
different medical indication. 
 
4.2 Inclusion criteria 
The following patients will be targeted for inclusion. 
 
Patients that meet the criteria for elective mitral valve repair surgery according to the 
European clinical guidelines (class I recommendation); 
o Symptomatic, chronic severe mitral valve insufficiency due to degenerative 
valve disease with a left ventricular ejection fraction (LVEF) >30%. 
o Asymptomatic, chronic severe mitral valve insufficiency due to degenerative 
valve disease with a LVEF <60% and/or a left ventricular end-systolic diameter 
(LVESD) >45 mm.  
 
4.3 Exclusion criteria 
Patients that will be excluded from our study are patients; 
 
 
not able to provide written informed consent. 
 
under the age of 18. 
 
with a history of cardiac surgery 
 
with AF 
 
with any comorbidity besides MVI. 
 
with claustrophobia or any other contra-indication for MRI 
o Each participant will be requested to fill out the “Questionnaire for MRI research 
with human volunteers” (“Vragenlijst voor MRI-onderzoek bij testpersonen”). 
This standard MRI safety document that is required to be filled in by anybody 
undergoing MRI scanning contains (among other items) questions on whether 

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or not the participant has ever had any surgical procedures, has any (metallic) 
implants or has any other metallic parts in his/her body e.g. splinters.  
 
4.4 Sample size calculation 
This study is designed as a pilot study, since we are the first to assess the effect of LA fibrosis 
and its characteristics prior to and after mitral valve repair surgery. 
 
Therefore we aim to include; 
- 
20 patients with MVI which are admitted to mitral valve repair surgery 
 

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5. METHODS 
5.1 Study parameters/endpoints 
5.1.1 Main study parameter/endpoint 
The main study parameters are:  
1. Severity of MVI prior to and after surgery (defined as regurgitation volume 
in ml) 
2. Left atrial remodelling prior to and after surgery 
o Left atrial volume 
o Calculated left atrial sphericity 
o Estimated wall tension (wall thickness, radius, pulmonary wedge 
pressure) 
o Mitral regurgitation flow measurement (quantitative) 
3. Presence and distribution patterns of LA fibrosis  
o Quantification of fibrosis surface (severity) 
o Geometric distribution of fibrosis (localization) 
4. Blood flow patterns in the LA (4D Flow) 
o Flow velocity (mean and peak) 
o Static fraction 
o Kinetic energy 
Secondary study parameters/endpoints -Fibrosis associated biomarkers derived from 
blood samples (NT-proBNP, TNF-β, Angiotensin II, cytokines)  
-Heart failure symptoms monitoring derived from questionnaire preoperative and at 
postoperative follow-up 
5.1.2 Other study parameters 
The following parameters will be recorded for each participant:  
- Clinical routine Cardiac MRI parameters (global volumes and function, T1 maps, 
ventricular fibrosis (LGE)) 
- Anthropometric data; height, weight 
- Clinical information potentially relevant to the study; medical history and medication 
use 
 
 
 
5.2 Study procedures 
CMR 

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We will recruit patients as outlined in paragraph 4.1. Patients will be asked to undergo 
a cardiac MRI scan protocol at the Amsterdam UMC (Location VUmc) prior to and after 
surgery. The MRI protocol will be conducted on a 1.5T MRI scanner at the Amsterdam 
UMC (Location VUmc), with the new 3D whole heart Works In Progress (WIP) package 
of Siemens. Standard cardiac coils will be used for image acquisition.  For triggering, 
ECG-gating and navigator-gating will be applied.  
 
Intravenous contrast (Gadolinium-based, 0.15mmol/kg) will be administered and total 
scan time will be approximately 60 minutes.  
 
Abstract outline scan protocol: 
1. Localizers 
2. LAX cines 
3. Contrast administration (Gadolinium) 
4. 3D MRA atria/ventricles 
5. Flow mitral valve (2D flow) 
6. Flow aortic valve (2D flow) 
7. 4D Flow scan 
8. 3D LGE 
9. SAX cines 
 
All scans will be performed using a 1.5 Tesla clinical MRI system (Siemens Sola, 
Erlangen, Germany) using a 32-channel array coil. The scan protocol included 
balanced SSFP cine imaging in long axis orientation (two-chamber and four-chamber 
view). An ECG-gated free-breathing 3D contrast-enhanced MR angiogram (CE-MRA) 
of the LA and pulmonary veins will be obtained immediately after a 20 mL (1 mL/sec) 
single dose bolus injection of contrast agent (Dotarem®, Guerbet, Roissy, France) 
followed by a body weight dependent slow infusion of contrast agent (slow infusion 
dose; 2.5-30.0 mL, infusion rate; 0.1-0.25 mL/sec) equal to a total dose of 0.4mL/kg.  
Typical acquisition parameters were: repetition time (TR)/ echo time (TE) 5.5/3.0 ms; 
flip angle, 25°; in-plane resolution 1.25 × 1.25 mm with slice thickness 2.5 mm 
(reconstructed to 0.625 × 0.625 × 1.25 mm). Immediately after contrast administration, 
first 2D flow data at the level of the mitral and aortic valve will be obtained. Then a 
prospective ECG-gated, 3-dimensional phase-contrast imaging with 3-directional 
velocity encoding (4D flow CMR) will be performed. Subsequently, high resolution 3D 
LGE images will be acquired using a navigator-based respiration- and ECG-gated 
inversion recovery prepared gradient echo pulse sequence applied between 15 and 25 

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minutes after contrast injection. Voxel size was 1.25 × 1.25 × 2.5 mm (reconstructed to 
0.625 × 0.625 × 1.25 mm). Other typical sequence parameters were as follows: 
TR/TE5.2/2.4 ms; flip angle, 20°. Finally a stack of short-axis cines will be obtained. 
 
In the occurrence of a clinical relevant incidental finding patients will be informed by 
their treating physician. During the informed consent patients will be notified of this 
obligation. Patients who refuse to be informed about clinical relevant incidental MRI 
findings, will be excluded from this study. 
 
MRI processing 
Quantification of LA fibrosis will be performed using commercially available ADAS 3D 
LA image post-processing software (Galgo Medical, Barcelona, Spain) and open-
source CEMRG image post-processing software (King’s College London, United 
Kingdom). The 3D LGE images will undergo stringent quality control (i.e. artefacts, 
proper myocardial nulling) by two experienced readers prior to post-processing and 
images will be excluded from analysis if quality is deemed insufficient.  
Figure 3. Left atrial 3D reconstruction from MRI. 
 
 
 
Left Atrial remodeling 
LA remodeling will be assessed by quantifying atrial sphericity and calculation of the 
wall tension calculation using Laplace’s law (T= p x r/2T). This calculation includes 
pulmonary wedge pressure which is determined using peri-operative Swan-Ganz 
based pressure measurements  during anesthesia, and radius based on atrial volume 
and wall thickness. Also the relation to quantitative MVI will be determined using 4D-
flow MRI processing.  
 
Presence and distribution of LA fibrosis 

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Quantification of fibrosis surface and the distribution of fibrosis will be assessed using 
LA 3D reconstructions based on 3D MRA data. Output of this data will be as shown 
below in Figure 4. The left atrial wall is segmented for accurate geometric localization 
of fibrosis (Figure 4A) and the severity of fibrosis will be shown as quantified surface 
area (Figure 4B). 
 
Figure 4. Left atrial segmentation (A) for accurate assessment of geometric distribution of fibrosis and 
severity of fibrosis shown as quantified surface (B). 
 
4D Flow 
4D-flow data will be corrected for Maxwell terms in the image reconstruction at the 
scanner, and velocity aliasing during post-processing. 4D flow data will be co-registered 
with the cine images to guide left atrial anatomic orientation. Mean and peak flow 
velocity data will be derived using dedicated research software (MASS version 2017-
Exp, Leiden University Medical Center, Leiden, the Netherlands). Furthermore, the 
volume fraction in the left atrium with a flow velocity below 10cm/s during the entire 
cardiac cycle will be determined. 
 
 
 
 
Blood samples 
Blood samples will be collected two weeks before and 3 months after surgery to assess 
biomarkers associated with atrial structural remodeling and/or fibrosis (NT-proBNP, 
TNF-β, Angiotensin II, cytokines). 

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5.3 Withdrawal of individual subjects 
Subjects can leave the study at any time for any reason if they wish to do so without any 
consequences. The investigator can decide to withdraw a subject from the study for urgent 
medical reasons. This will be correlated with CMR derived LA fibrosis. 
 
5.4 Replacement of individual subjects after withdrawal 
Upon withdrawal of a subject, the data collected will not be used for the study and will be 
deleted. 
 
5.5 Follow-up of subjects withdrawn from treatment 
Not applicable. 
 
5.6 Premature termination of the study 
Study participants can withdraw their consent at any time during the MRI protocol. However, 
since patients with claustrophobia will not be included in the study, it is unlikely that patients 
who have agreed to participate will withdraw during the 45 min MRI protocol. In addition, since 
all the elements of this study are harmless and carry no risk, it is unlikely that this will occur. 
 
5.7 Potential risk analysis due to COVID-19 regulations 
The main risk for our study due to unexpected upscaling of COVID-19 regulations would be 
the delay of elective surgical mitral valve repair procedures. This would be due to a 
(temporary) reduced intensive care unit capacity. However, this would not impact the study 
feasibility, as a consequence the study will take longer to include the target number of 
inclusions. Other study related procedures would not be affected by COVID-19 as these are 
reserved for research purposes. 
 
6. SAFETY REPORTING 
 
6.1 Temporary halt for reasons of subject safety 
In accordance to section 10, subsection 4, of the WMO, the researchers will suspend the 
study if there is sufficient ground that continuation of the study will jeopardise subject health 
or safety.  The researchers will notify the accredited METC without undue delay of a 
temporary halt including the reason for such an action. The study will be suspended 
pending a further positive decision by the accredited METC. The investigator will take care 
that all subjects are kept informed.  

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6.2 AEs and SAEs 
6.2.1 Adverse events (AEs) 
Adverse events are defined as any undesirable experience occurring to a subject 
during the study considered related to MRI procedure. All adverse events reported 
spontaneously by the subject or observed by the investigator or his staff will be 
recorded. 
6.2.2 Serious adverse events (SAEs) 
A serious adverse event is any untoward medical occurrence or effect that  
- 
results in death; 
- 
is life threatening (at the time of the event); 
- 
requires hospitalisation or prolongation of existing inpatients’ hospitalisation; 
- 
results in persistent or significant disability or incapacity; 
- 
is a congenital anomaly or birth defect; or 
- 
any other important medical event that did not result in any of the outcomes listed 
above due to medical or surgical intervention but could have been based upon 
appropriate judgement by the investigator. 
An elective hospital admission will not be considered as a serious adverse event. 
 
The additional risks associated with participation in this study are considered minimal. 
Gadolinium is a safe contrast agent, which is frequently used in clinical practice. 
Intravenous gadolinium administration may cause minimal injection site reactions (e.g. 
pain, cold or burning sensation). As with other contrast-agents, anaphylactic-like 
reactions can occur, although this is very unusual. 
 
Nevertheless, the investigators will report all SAEs to the accredited METC without 
undue delay after obtaining knowledge of the events. The researchers will report the 
SAEs through the web portal ToetsingOnline to the accredited METC that approved the 
protocol, within 7 days of first knowledge for SAEs that result in death or are life 
threatening followed by a period of maximum of 8 days to complete the initial 
preliminary report. All other SAEs will be reported within a period of maximum 15 days 
after the researchers have first knowledge of the serious adverse events. 
 

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6.3 Follow-up of adverse events 
All AEs will be followed until they have abated, or until a stable situation has been reached. 
Depending on the event, follow up may require additional tests or medical procedures as 
indicated, and/or referral to the general physician or a medical specialist. 
SAEs need to be reported till end of study within the Netherlands, as defined in the protocol. 
6.4 Incidental medical findings 
Incidental medical findings for which medical follow-up is required will be reported to the 
patient self and his/her general practitioner. Patients who do not wish to know about 
incidental findings are not allowed to participate in this study. This is also mentioned in the 
informed consent form of this study. 
 
 
 

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7. STATISTICAL ANALYSIS 
7.1 Primary study parameters 
CMR qualitative and quantitative analyses will be performed on a dedicated work-station 
with counseling of investigators experienced in the post-processing of CMR techniques.  
 
The included data will be presented as mean ± standard deviation. Ratios will be given for 
statistical assessment of non-continuous variables. Correlation analyses will be used to 
analyze differences between continuous parameters. Confidence intervals (95%) will be 
used and a p<0.05 will be considered statistically significant. Fisher exact test will be 
performed to verify significance, risk ratio (RR) and 95% confidence intervals. SPSS 26.0 
(SPSS Inc, Chicago, IL) for Windows is used to assess statistical analyses. 
 
7.2 Secondary study parameter 
Analysis of the obtained bloodsamples for fibrosis associated biomarkers will be performed 
by the department of laboratory medicine and pathology of the AmsterdamUMC (location 
AMC).  
 
7.3 Other study parameters 
Continuous data will be presented as mean with standard deviation or median with range. 
Categorical data are presented as proportions. Tables will summarize patient 
characteristics, clinically relevant parameters and routine MRI parameters (enddiastolic 
and endsystolic volumes, stroke volume, ejection fraction). 
 
 
 
 
 
 
 
 
 
 
 

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8. ETHICAL CONSIDERATIONS 
8.1 Regulation statement 
This study will be conducted according to the principles of the Declaration of Helsinki 
(version 2013, Fortaleza, Brazil) and in accordance with the Medical Research Involving 
Human Subjects Act (WMO).  
 
8.2 Recruitment and consent 
Eligible patients will be recruited from a surgery waiting-list/ database of the Heartcenter. Since 
only healthcare providers with  a treatment-relationship with the patient have access the patient 
record file, the treating physician  will be asked for permission by the investigator (S. el Mathari) 
to contact the patient by phone on his/her behalf to inquire if the patient is interested in study 
participation. . And if so, patient information will be sent to their home address. Patients will be 
then given 5 days to read the patient information and to consider the study participation. After 
this 5-day period, the patients will be contacted again by the aforementioned investigator. If 
they are willing to participate, the MRI prior to surgery will be scheduled and an MRI slot after 
surgery will be allocated. Also, the informed consent form will be signed before the first MRI 
scan is performed.  
8.3 Benefits and risks assessment, group relatedness 
This is an MRI study with use of contrast media (Gadolinium). Gadolinium-based contrast 
enhanced imaging is considered the clinical gold standard for identifying cardiac fibrosis in 
both the ventricles and atria. [10, 11] Unfortunately, reliable assessment of atrial fibrosis 
without use of a contrast agent is currently not feasible.  
 
Although rarely reported in previous literature, nephrogenic systemic fibrosis (NSF) is a more 
common side effect associated with gadolinium than brain damage. In addition, NSF was 
more commonly associated with contrast agents with a linear molecular structure. However, 
in this study we will use the contrast agent gadoterate meglumine (Dotarem®). This is a 
macrocyclic contrast agent with  great stability and low risk profile. [12] This favorable profile 
was recently reconfirmed. In a large cohort, it was demonstrated that gadoterate meglumine 
is a safe contrast agent. In only 70 (0.12%) out of 35.499 patients who underwent contrast 
enhanced MRI with gadoterate meglumine, a transient adverse event occurred (urticaria 
0.03%, nausea 0.02%, vomiting 0.01%, respectively). In none of the patients NSF was 
observed. [13] Based on these reports, we believe it is safe and justifiable to use gadoterate 
meglumine for this study at a dose recommended in the literature. 

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The use of the contrast agent and potential side effects associated with administration, 
including transient cold/burning sensation, urticaria, nausea and vomiting will be described in 
the information letter. 
 
There are no direct benefits for individuals participating to our study.  
 
8.4 Compensation for injury 
 
The investigator (AMC) has a liability insurance which is in accordance with article 7 of 
the WMO. 
  
The investigator (AMC) also has an insurance which is in accordance with the legal 
requirements in the Netherlands (Article 7 WMO). This insurance provides cover for 
damage to research subjects through injury or death caused by the study. 
The insurance applies to the damage that becomes apparent during the study or within 4 
years after the end of the study. 
 
8.5 Incentives 
The subjects will receive no financial compensation or other incentives.  

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9. ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION 
9.1 Handling and storage of data and documents 
The participant’s identity will remain confidential. His or her name will not be published and 
will not be disclosed to anyone outside the research group. All personal details and other 
identifiable data provided or collected during this study will be kept in the strictest 
confidence. Participants will be assigned a code number following their first contact with 
the researcher. This number will be used throughout the project and will be the only 
identifier on physiological archival data and MRI data. No identifiable (e.g. name etc.) of 
participants will be revealed at scientific meetings, conferences, presentations, publications 
or any other vehicles of public communication. In any such publication arising from this 
research the individual results will not be identifiable. Only the research team will have 
access to the collected data. 
 
- 
Each researcher will store documents bearing identifiable and personal information in 
a locked cabinet with access strictly restricted to members of the research group. 
- 
All computerised data/information will be stored on pass-word protected computers, to 
which only a member of the research team has access. 
- 
Code numbers will be used for all computerised data/information collected. These data 
are therefore stored in a coded fashion. 
- 
All gathered data/information will be stored for the duration of the study. It will then be 
kept in a locked cabinet for up to 15 years 
 
9.2 Amendments  
Amendments are changes made to the research after a favourable opinion by the 
accredited METC has been given. All amendments will be notified to the METC that gave 
a favourable opinion.  
 
9.3 Annual progress report 
The investigator will submit a summary of the progress of the trial to the accredited METC 
once a year. Information will be provided on the date of inclusion of the first subject, 
numbers of subjects included and numbers of subjects that have completed the trial, 
serious adverse events/ serious adverse reactions, other problems, and amendments.  
 

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9.4 Temporary halt and (prematurely) end of study report 
The investigator will notify the accredited METC of the end of the study within a period of 8 
weeks. The end of the study is defined as the last patient’s last visit.  
 
The investigator will notify the METC immediately of a temporary halt of the study, including 
the reason of such an action.  
    
In case the study is ended prematurely, the investigator will notify the accredited METC 
within 
15 
days, 
including 
the 
reasons 
for 
the 
premature 
termination. 
 
Within one year after the end of the study, the investigator will submit a final study report 
with the results of the study, including any publications/abstracts of the study, to the 
accredited METC.  
 
9.5 Public disclosure and publication policy 
This project is not sponsored and no special arrangements are made regarding the 
disclosure of publication material and will be disclosed unreservedly.  
 
9.6 Monitoring and Quality Assurance 
Monitoring of the conduct of the study by the Clinical Monitoring Center (CMC) of the 
AmsterdamUMC. The CMC performs quality control measurements to ensure protection of the 
rights, safety and well-being of the research subjects and scientific quality of the research data. 
After approval of the protocol by the METC the investigators will have an intake appointment 
with the CMC to prepare a monitoring plan. The monitoring visits will be planned and the 
frequency of these visits will be conform the NFU-standards depending on the risk-stratification 
and duration of the study. 
 
 
 
 
 
 
 
 
 
 
 

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10. REFERENCES 
 
1. Muller, H., et al., Biatrial anatomical reverse remodelling after radiofrequency catheter 
ablation for atrial fibrillation: evidence from real-time three-dimensional 
echocardiography. Europace, 2008. 10(9): p. 1073-8. 
2. Frangogiannis, N.G., The Extracellular Matrix in Ischemic and Nonischemic Heart Failure. 
Circulation Research, 2019. 125(1): p. 117-146. 
3. Liao, C.H., et al., Cardiac mast cells cause atrial fibrillation through PDGF-A-mediated 
fibrosis in pressure-overloaded mouse hearts. Journal of Clinical Investigation, 2010. 
120(1): p. 242-253. 
4. Gonzalez, A., et al., Myocardial Interstitial Fibrosis in Heart Failure Biological and 
Translational Perspectives. Journal of the American College of Cardiology, 2018. 
71(15): p. 1696-1706. 
5. Chelu, M.G., et al., Atrial Fibrosis by Late Gadolinium Enhancement Magnetic Resonance 
Imaging and Catheter Ablation of Atrial Fibrillation: 5-Year Follow-Up Data. Journal of 
the American Heart Association, 2018. 7(23). 
6. Dzeshka, M.S., et al., Cardiac Fibrosis in Patients With Atrial Fibrillation Mechanisms and 
Clinical Implications. Journal of the American College of Cardiology, 2015. 66(8): p. 
943-959. 
7. Nishimura, R.A., et al., Mitral valve disease--current management and future challenges. 
Lancet, 2016. 387(10025): p. 1324-34. 
8. Lazam, S., et al., Twenty-Year Outcome After Mitral Repair Versus Replacement for 
Severe Degenerative Mitral Regurgitation: Analysis of a Large, Prospective, 
Multicenter, International Registry. Circulation, 2017. 135(5): p. 410-422. 
9. Baumgartner, H., et al., 2017 ESC/EACTS Guidelines for the management of valvular 
heart disease. European Heart Journal, 2017. 38(36): p. 2739-2791. 
10. Wagner A, Mahrholdt H, Holly TA, Elliott MD, Regenfus M, Parker M, et al. Contrast-
enhanced MRI and routine single photon emission computed tomography (SPECT) perfusion 
imaging for detection of subendocardial myocardial infarcts: an imaging study. Lancet. 
2003;361(9355):374-9. 
11. Kholmovski EG, Morris AK, Chelu MG. Cardiac MRI and Fibrosis Quantification. Card 
Electrophysiol Clin. 2019;11(3):537-49. 
12. Shellock FG, Spinazzi A. MRI safety update 2008: part 1, MRI contrast agents and 
nephrogenic systemic fibrosis. AJR Am J Roentgenol. 2008;191(4):1129-39. 
13. Soyer P, Dohan A, Patkar D, Gottschalk A. Observational study on the safety profile of 
gadoterate meglumine in 35,499 patients: The SECURE study. J Magn Reson Imaging. 
2017;45(4):988-97.