Non-invasive quantitative characterization of aortic valve tissue composition from computed tomography angiography improves patient risk stratification in transcatheter aortic valve implantation

Abstract

Abstract Background Computed tomography angiography (CTA) performed for procedural planning of transcatheter aortic valve implantation (TAVI) can be used for a more complete characterization of aortic valve tissue beyond calcium assessment. Combining quantitative data on both noncalcified and calcified tissues may improve differentiation of aortic stenosis (AS) subtypes and prognostication post-TAVI. Purpose We sought to noninvasively assess aortic valve tissue composition with quantitative cardiac CTA in patients with AS and its prognostic vaalue in those who underwent TAVI. Methods In 185 consecutive AS patients in a prospective registry who underwent cardiac CTA before TAVR and 90 matched controls with normal aortic valves, non-luminal aortic valve tissue were identified using semi-automated software as non-calcified (low-attenuation [−30 to 30 Hounsfield Units (HU)], fibro-fatty (31 to 130 HU), fibrous (131 to 350 HU) and calcified (>650 HU) tissue; with total tissue as (non-calcified + calcified components). Volumes of each component and composition [(tissue component volume/total tissue volume) ×100%] were quantified. The association of aortic valve composition and clinical outcomes post-TAVI including all-cause mortality was evaluated using Valve Academic Research Consortium (VARC)-2 definitions. Results AS patients had greater aortic valve tissue volume (median 2000.2, vs 527.8 mm3, p<0.001) with a higher calcified tissue composition (41.8% vs 3.4%, p<0.001) compared to controls. Total aortic valve tissue (noncalcified and calcified) volume yielded the highest area under the operating curve (AUC) for diagnosing severe AS (0.93,95% CI:0.93–0.99) as compared to calcified tissue volume alone (0.87,95% CI:0.81–0.94, p=0.002). Low-flow low-gradient AS was associated with increase in total tissue volume compared to controls (1515.3 vs 527.8 mm3, p<0.001), with lower volumes of calcified tissue than high-gradient AS (412.5 vs 829.6 mm3, p<0.001). Device success was achieved in 88% (164 of 185) patients and prevalence of moderate or severe paravalvular leak was 3.8%, however no differences between in aortic valve composition were observed in patients with and without device success. Early safety endpoints occurred in 16.1% (29 of 180) patients and 30-day all-cause mortality was 4.4%. Whereas only calcified tissue volume was related to VARC-2 early safety, AUC for prediction of 30-day mortality post-TAVI was 0.793 (95% CI:0.685–0.901) for total tissue volume and 0.776 (95% CI:0.676–0.876) for calcified tissue volume. Conclusions Quantitative CTA assessment of aortic valve tissue volume and composition can improve identification of high-gradient AS and low-flow low-gradient AS patients referred for TAVI and predict 30-day mortality post-TAVI. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Heart, Lung, and Blood Institute (NHLBI)