Metrics details The increasing prevalence of patients with aortic stenosis worldwide highlights a clinical need for improved and accurate prediction of clinical outcomes following surgery We investigated patient demographic and cardiovascular magnetic resonance (CMR) characteristics to formulate a dedicated risk score estimating long-term survival following surgery We recruited consecutive patients undergoing CMR with gadolinium administration prior to surgical aortic valve replacement from 2003 to 2016 in two UK centres A total of 250 patients were included (68 ± 12 years with pre-operative mean aortic valve area 0.93 ± 0.32cm2 LVEF 62 ± 17%) and followed for 6.0 ± 3.3 years Multivariable analysis showed that increasing age (HR 1.04 presence of infarction or midwall late gadolinium enhancement (HR 1.52 and HR 2.14 respectively higher indexed left ventricular stroke volume (HR 0.98 P = 0.043) and higher left atrial ejection fraction (HR 0.98 P = 0.083) associated with mortality and developed a risk score with good discrimination This is the first dedicated risk prediction score for patients with aortic stenosis undergoing surgical aortic valve replacement providing an individualised estimate for overall mortality This model can help clinicians individualising medical and surgical care Trial Registration ClinicalTrials.gov Identifier: NCT00930735 and ClinicalTrials.gov Identifier: NCT01755936 there is currently no dedicated risk score derived specifically for patients undergoing surgical aortic valve replacement (SAVR) for estimating long-term mortality to allow clinicians to facilitate precision medicine mortality remains high and Euroscore II and STS models whilst predicting in-hospital and 30-day mortality they lack the inclusion of myocardial fibrosis in their models which is a known risk factor although individual predictors have already been investigated including LVEF and midwall fibrosis no score is currently available to bring all those parameters together in predicting risk In this study we investigated the additional role of LGE-CMR in developing a mortality risk score for patients undergoing SAVR in two institutions and identified predictors of survival following aortic valve replacement Consecutive patients with aortic stenosis undergoing LGE-CMR and subsequent SAVR were recruited from two large prospective observational registries: the Royal Brompton Hospital of Imperial College UK including patients from 2003–2016 (ClinicalTrials.gov Identifier: NCT00930735 June 30th 2009) and the Edinburgh Heart Centre Royal Infirmary of University of Edinburgh UK including patients from 2013 to 2016 (ClinicalTrials.gov Identifier: NCT01755936 The present study is not associated with the objectives of these trials and does not report results associated with or generated from these trials It uses clinical data generated from these trials to investigate the specific objective mentioned above The study was conducted in accordance with the Declaration of Helsinki after local research ethics approval and written patient consent Medical history and demographic characteristics were collected following patient interviews and review of the hospital and community records Coronary artery disease was defined as prior coronary revascularization or the presence of significant coronary artery stenosis as assessed by invasive or computed tomography coronary angiography by > 50% lumen diameter narrowing steady-state free precession sequences were used for aortic valve planimetry (two orthogonal coronal views were taken and then sagittal “valve stack” imaging starting at ~ 10 mm below the level valve and extending to ~ 10 mm above the level of the valve) and assessment of biventricular volumes and LV mass Ten to fifteen minutes after injection of 0.1 mmol/kg of gadolinium contrast agent (Gadovist Germany) inversion recovery–prepared spoiled gradient echo images were acquired in standard long- and short-axis views to detect areas of LGE communication with primary care and through the Office of National Statistics where there is compulsory registration of all deaths All statistical analyses were carried out using STATA (14 Variables are expressed as mean ± standard deviation (SD) median and interquartile range (IQR) or counts and percentages as appropriate The follow-up time for each patient was calculated from the day of CMR to the date of death or their most recent evaluation The annual event rate was calculated by dividing the number of patients reaching the endpoint by the total follow-up period for that endpoint The cumulative probability for the occurrence of an outcome was estimated using the Kaplan–Meier method No variable had more than 10% of data missing multiple imputation was undertaken in variables with any missing data as described in Supplementary Material Methods UK National Ethics approval from London and Lothian were obtained Institutional Board approval from Edinburgh Royal Infrimary and Royal Brompton Hospital and written informed patient consent were obtained Edinburgh 39) were included in this study: age 68 ± 12 years There were 161 patients with isolated SAVR A total of 168 (67%) patients had severe aortic stenosis while 82 (33%) had moderate aortic stenosis All the patients with moderate aortic stenosis had a concomitant CABG Coronary artery disease was present in 114 (46%) and 37 (15%) patients had low flow (defined by LV stroke volume < 35mls/m2) (Table 1) CMR was performed at a median of 56 days before the operation (range 14–184) The patients were followed for a mean 6.0 ± 3.3 years having moved abroad and censored at the last time known to be alive Kaplan–Meier estimator plot of survival in patients with no gadolinium enhancement midwall enhancement and infarction pattern enhancement This plot indicates significantly worse prognosis in the patients with either form of enhancement (midwall or infarction) out to 10 years (log rank P = 0.029) Patients with a mixed pattern of LGE were categorized according to the predominant pattern of fibrosis The presence of either midwall fibrosis or infarction pattern fibrosis was associated with worse outcome when compared to absence of fibrosis (Fig. 1) Observed vs predicted risk of mortality for patients following SAVR The observed (black) vs predicted (grey) risk of mortality for patients following SAVR out to 10 years in clinically relevant risk groups is shown The predictions for the risk of death at 10 years can be obtained by the following equation: and infarction LGE are assigned the value 1 if present or zero if absent emphasising the importance of regular review and medical optimisation following surgery Although generic models for predicting survival after open heart surgery exist and are used in clinical practice to identify high risk patients these are not designed specifically for SAVR and importantly are not specific for estimating long-term survival A tool for estimating long-term survival following SAVR is therefore needed to enable individualised decisions for patients We have developed and internally validated a risk score using the most significant variables that can be used to identify patients at risk of overall mortality after SAVR We have used a pragmatic cohort of patients undergoing routine guideline-based surgery to ensure our findings are clinically relevant reflecting the routine patient demographics The aim of this work was not to identify the correct surgical “window” for patients with AS but to identify pre-operative predictors of survival a model looking at overall mortality in patients who have undergone surgical SAVR based on the existing guidelines is able to identify patients with a high risk of mortality High-risk patients may benefit from more frequent medical care by physicians and cardiologists This model will also allow clinicians to consider longer-term outcomes in patients as currently the use of Euroscore II and STS only allows short-term outcome prediction One important novel finding is the prognostically beneficial use of antiplatelet therapy In the UK if patients take antiplatelet therapy before surgery this is continued long-term unless anticoagulation is needed Multivariable analysis showed use of antiplatelets was associated with an almost 50% reduction in overall mortality independently of presence or absence of coronary disease This suggests that patients with AS undergoing SAVR may represent a cohort of patients at high vascular risk who might benefit from antiplatelet therapy in the long term As our cohort of patients was elderly and the vast majority received a tissue bioprosthesis (> 90%) we estimate that the continuation of aspirin or clopidogrel could also have had an impact in reducing tissue thrombosis and hence improve survival We provide a validated score with predictive variables for calculating mortality risk out to 10 years to identify patients at higher risk following the SAVR that could benefit from being followed up in the hospital cardiology outpatients or the community more closely this score is applicable not only to the patients with severe AS undergoing SAVR but also to the patients with moderate AS and co-existent CAD undergoing SAVR and CABG as our model is derived from prognostically important risk factors it subsequently enables early identification of the patients that carry high risk of mortality post intervention the individual patient might still fare much better with surgery than medical management the aim of the score is to facilitate more tailored post-operative management as this falls out of the scope and purpose of the model this score could be routinely utilised for selecting patients for transcatheter aortic valve replacement in preference to the non-specific Euroscore II and STS although evidence from randomised controlled trials would be invaluable in validating this our results indicate that use of an antiplatelet at the time of CMR is associated with significantly improved mortality This is a novel finding suggesting SAVR patients represent a cohort with high vascular risk that might benefit from antiplatelet therapy independently from other comorbidities This work lends support to this hypothesis and further studies will be needed it is uncertain whether this risk score will be valid in this population or whether a different risk score needs to be designed this score is robust and internally validated using the strongest statistical validation mechanism possible In this large prospective registry-based study with the longest follow-up to date we show that the risk of mortality in patients following SAVR remains high We identify that the age of the patient at the time of SAVR presence of any myocardial fibrosis and use of antiplatelet therapy can be utilised to provide an estimate of mortality for such patients through a risk score and help guide management both before and after surgery All data can be obtained following reasonable 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W. L. et al. Myocardial fibrosis and cardiac decompensation in aortic stenosis. JACC Cardiovasc. Imaging. https://doi.org/10.1016/j.jcmg.2016.10.007 (2016) Vassiliou, V. S. et al. Lipoprotein(a) in patients with aortic stenosis: Insights from cardiovascular magnetic resonance. PLoS One 12, 195. https://doi.org/10.1371/journal.pone.0181077 (2017) Magnetic resonance to assess the aortic valve area in aortic stenosis AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Left atrial dilation in patients with heart failure and preserved ejection fraction: Insights from cardiovascular magnetic resonance Early anticoagulation of bioprosthetic aortic valves in older patients Prospective evaluation of clinical outcomes in all-comer high-risk patients with aortic valve stenosis undergoing medical treatment transcatheter or surgical aortic valve implantation following heart team assessment Prognostic implications in patients with symptomatic aortic stenosis and preserved ejection fraction: Japanese multicenter aortic stenosis Long-term outcomes following surgical aortic bioprosthesis implantation An evaluation of penalised survival methods for developing prognostic models with rare events A novel clinical risk prediction model for sudden cardiac death in hypertrophic cardiomyopathy (HCM Risk-SCD) Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD Statement On the C-statistics for evaluating overall adequacy of risk prediction procedures with censored survival data Impact of stroke volume on severe aortic stenosis in patients with normal left ventricular function Mangner, N. et al. Predictors of mortality and symptomatic outcome of patients with low-flow severe aortic stenosis undergoing transcatheter aortic valve replacement. J. Am. Heart Assoc. https://doi.org/10.1161/JAHA.117.007977 (2018) Low-flow/low-gradient- aortenklappenstenose: Klinisches und diagnostisches spektrum Clinical implication of mitral annular plane systolic excursion for patients with cardiovascular disease Assessment of subclinical left ventricular dysfunction in aortic stenosis Prediction models need appropriate internal Magnetic resonance imaging phantoms for quality-control of myocardial T1 and ECV mapping: specific formulation long-term stability and variation with heart rate and temperature Aortic flow patterns and wall shear stress maps by 4D-flow cardiovascular magnetic resonance in the assessment of aortic dilatation in bicuspid aortic valve disease Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients Download references The authors would like to acknowledge the support from the research nurses from the NIHR Biomedical Research Unit Royal Brompton and Harefield Hospitals and Imperial College London This work was supported by the NIHR Biomedical Research Unit the British Heart Foundation (BH FS/15/29/31492; CER FS/14/13/30619; RE DEN CH/09/002; MRD FS/14/78/31020); DEN was also supported by a Wellcome Trust Senior Investigator Award (WT103782AIA) These authors jointly supervised this work: Marc R Royal Brompton Hospital and National Heart and Lung Institute analysed data and drafted the first manuscript analysed data and substantially revised the first draft analysed and interpreted data and revised the draft analysed and interpreted data and substantially revised the manuscript analysed data and substantially revised the first draft designed the work and substantially revised the manuscript designed the work and substantially revised the first draft conceived the idea and substantially revised the first draft All authors read and approved the final manuscript and agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work even ones in which the author was not personally involved and the resolution documented in the literature Dr Vassiliou is an Editorial Board Member of Scientific Reports Pennell has received research funding from Siemens and La Jolla; has served as a consultant to Bayer; and is a director of and shareholder in CVIS Prasad has received honoraria for talks from Bayer Schering All others authors declare no conflict of interest Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Download citation DOI: https://doi.org/10.1038/s41598-021-99788-7 Anyone you share the following link with will be able to read this content: a shareable link is not currently available for this article Sign up for the Nature Briefing newsletter — what matters in science «We began today with Met Curator Dita Amory's lecture on azulejos The word "azulejo" comes from the Arabic word "zellige," or "polished stone." Throughout Spain and Portugal you can't help but marvel at these incredible decorative motifs which were originally introduced by the Moors.» Portugal began producing its own decorative tiles which were not only beautiful but also helped with insulation churches began using them to depict religious scenes Large azulejo panels were also featured in the homes of wealthy families or fantastic images of Portuguese explorers Portugal was the world's largest producer of decorative tiles where the local vinho verde (wine) is made Lecturer Paddy Bowe led us on a tour of the enchanting gardens After a walk through the estate's brandy cellars the group enjoyed a delicious wine tasting paired with various fruit we dined over candlelight at the Alpendurada Monastery where a Benedictine Order of monks resided until 1834 Read today's Portuguese stories delivered to your email We appreciate that not everyone can afford to pay for our services but if you are able to we ask you to support The Portugal News by making a contribution – no matter how small You can change how much you give or cancel your contributions at any time Send us your comments or opinion on this article Reaching over 400,000 people a week with news about Portugal Regeneration of the magnificent Grade I listed Piece Hall in Halifax has been made possible with Hardscape paving and landscaping As part of a £19million conservation scheme the Piece Hall has undergone a major transformation to revive the cultural The Piece Hall was originally built to support the trading of ‘pieces’ of cloth The historic site is one of the last remaining examples of eighteenth century architecture of its kind Landscaping materials supplier Hardscape played an integral role in the regeneration project, working alongside Gillespies landscape architects and GRAHAM Construction to restore the central courtyard to its former glory Supported by Calderdale Council and a number of key conservation and heritage foundations the redesign includes three levels of shops Widely recognised as Yorkshire’s most important secular building the regeneration of the Piece Hall was a major undertaking for all involved Hardscape was tasked with bringing Gillespies’ architectural vision to life transforming the courtyard to create an attractive open and accessible central square for both residents and visitors to congregate The landscaping needed to provide a contemporary and flexible space that could host a seasonal programme of events and festivals and accommodate an increased footfall As the project was supported by the Heritage Lottery Fund it was of paramount importance that materials were sourced from within Europe and that the style texture and finish would be sympathetic with the original design of the main building Hardscape provided a range of premium landscaping products to complement the site’s heritage and enhance the original eighteenth century design This included six bespoke water features and more than 40 granite and timber benches which would be enhanced by atmospheric lighting.  Hardscape also provided 12 solid granite benches and 40 Iroko timber-topped granite benches which was left exposed beneath the Iroko timber to reveal the Piece Hall logo The benches are illuminated at night by a set of unique light fittings which provide added atmospheric effects to the already dramatic setting fountain designers and landscape architects Hardscape designed and detailed six water fountains Each fountain was constructed out of more than 50 bespoke designed Alpendurada units Hardscape invited the GRAHAM Construction team to visit their quarries and manufacturing facilities in the Alpendurada region in Portugal Here they were able to gain a better understanding of how the material is quarried The installation process was complex because every part of the enclosed courtyard was under construction throughout the contract which meant there was no space for storage of materials As groundworks completed in different parts in the courtyard Hardscape had to respond quickly by arranging the delivery of materials required for that specific section Hardscape worked closely with GRAHAM to build individual schedules by dividing the courtyard into four quarters which enabled the quarries in Portugal to co-ordinate the speedy manufacture of materials The Piece Hall’s new look was revealed at a grand opening ceremony in August 2017 More than 22,000 people walked through the gates for the event and the feedback was resoundingly positive managing director at Hardscape, said: 'The regeneration of the Piece Hall provides a new shared space to bring the local community together and we hope the new courtyard will continue to inspire this spirit of collaboration for years to come The final result is breath-taking and we are proud to have been involved in preserving such an iconic treasure of British heritage.' 'This is the single largest area of Forest Pennant paving ever laid and it is stunning. Specified for its complementary and indigenous properties our Pennant sandstone harmonises with the building fabric of the Piece Hall and proves the value of considered public realm investment. I wish to thank my team at Forest of Dean Stone Firms and all at Hardscape for delivering such a powerful space.' For more information or technical support visit: www.hardscape.co.uk enq@hardscape.co.uk updates and our weekly newsletter – all designed to bring you the best stories from RIBAJ.com