Association of Acylcarnitines With Left Ventricular Remodeling in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement
Authors: Sammy Elmariah, Laurie A. Farrell, Deborah Furman, Brian R. Lindman, Xu Shi, Jordan E. Morningstar, Eugene P. Rhee, Robert E. Gerszten
Journal: JAMA Cardiology (2018)

<h3>Importance</h3> Clinical practice guidelines currently endorse a reliance on clinical symptoms of overt left ventricular (LV) failure to time aortic valve replacement for severe aortic stenosis; however, delayed aortic valve replacement can result in irreversible LV injury and adverse outcomes. Blood metabolomic signatures possess prognostic value in heart failure; this study assesses whether they are informative in aortic stenosis. <h3>Objective</h3> To evaluate the value of metabolomic signatures in reflecting the extent of maladaptive LV remodeling in patients with end-stage aortic stenosis undergoing transcatheter aortic valve replacement, and to assess whether this procedure reverses metabolomic aberrations. <h3>Design, Setting, and Participants</h3> This study of 44 patients with symptomatic severe aortic stenosis who underwent transfemoral transcatheter aortic valve replacement at a single-center tertiary care hospital. Liquid chromatography–mass spectrometry-based metabolomic profiling was performed on blood samples collected before and 24 hours after the procedure, and analyses were conducted to identify metabolites related to the measures of LV remodeling. <h3>Main Outcomes and Measures</h3> We evaluated LV ejection fraction, LV mass index, and relative wall thickness, as well as levels of the acylcarnitines C16, C18:1, C18:2, C18, C26, choline, and kynurenine. <h3>Results</h3> We enrolled 44 patients with severe aortic stenosis with a mean (SD) age of 81.9 (8.5) years, of whom 23 (52%) were women. The mean (SD) LV ejection fraction was 56.7% (18.2%), mean (SD) LV mass index was 117.3 (41.4) g/m<sup>2</sup>, and relative wall thickness was 0.53 (0.14). The mean β values of acylcarnitines C16, C18:1, C18:2, C18, and C26 were independently associated with LV mass index (C16: mean, 19.24; 95% CI, 5.48-33.01;<i>P</i> = .008; C18:1: mean, 26.18; 95% CI, 14.04-38.32;<i>P</i> &lt; 1.0 × 10<sup>-4</sup>; C18:2: mean, 17.42; 95% CI, 3.40-31.43;<i>P</i> = .02; C18: mean, 25.25; 95% CI, 10.91-39.58;<i>P</i> = .001; C26: mean, 19.93; 95% CI, 4.41-35.45;<i>P</i> = .01), even after adjustments for age, sex, diabetes status, renal function, and B-type natriuretic peptide (BNP). Circulating levels of C18:2 acylcarnitine were associated with LV ejection fraction before and after multivariable adjustment (mean, −6.11; 95% CI, −10.88 to 1.34;<i>P</i> = .01). Blood metabolite levels did not independently relate to relative wall thickness. Within 24 hours of transcatheter aortic valve replacement, circulating levels of C16 decreased by 30.2% (<i>P</i> = 7.3 × 10<sup>-6</sup>), C18:1 by 42.7% (<i>P</i> = 3.7 × 10<sup>-8</sup>), C18:2 by 37.3% (<i>P</i> = 5.1 × 10<sup>-6</sup>), and C18 by 38.3% (<i>P</i> = 3.4 × 10<sup>-5</sup>). <h3>Conclusions and Relevance</h3> In symptomatic patients with severe aortic stenosis undergoing transcatheter aortic valve replacement, circulating levels of long-chain acylcarnitines were independently associated with measures of maladaptive LV remodeling, and metabolic perturbations lessened after procedure completion. Further efforts are needed to determine the clinical applicability of these novel biomarkers.