CTA pulmonary artery enlargement in patients with severe aortic stenosis: Prognostic impact after TAVR

Valery L Turner; Ayman Jubran; Juyong Brian Kim; Eva Maret; Kegan J Moneghetti; Francois Haddad; Myriam Amsallem; Marina Codari; Virginia Hinostroza; Domenico Mastrodicasa; Anna M Sailer; Yukari Kobayashi; Takeshi Nishi; Alan C Yeung; Amelia C Watkins; Anson M Lee; D Craig Miller; Michael P Fischbein; William F Fearon; Martin J Willemink; Dominik Fleischmann

doi:10.1016/j.jcct.2021.03.004

CTA pulmonary artery enlargement in patients with severe aortic stenosis: Prognostic impact after TAVR

J Cardiovasc Comput Tomogr. 2021 Sep-Oct;15(5):431-440. doi: 10.1016/j.jcct.2021.03.004. Epub 2021 Mar 21.

Authors

Valery L Turner¹, Ayman Jubran², Juyong Brian Kim³, Eva Maret⁴, Kegan J Moneghetti⁵, Francois Haddad⁶, Myriam Amsallem⁷, Marina Codari⁸, Virginia Hinostroza⁹, Domenico Mastrodicasa¹⁰, Anna M Sailer¹¹, Yukari Kobayashi¹², Takeshi Nishi¹³, Alan C Yeung¹⁴, Amelia C Watkins¹⁵, Anson M Lee¹⁶, D Craig Miller¹⁷, Michael P Fischbein¹⁸, William F Fearon¹⁹, Martin J Willemink²⁰, Dominik Fleischmann²¹

Affiliations

¹ Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: vturner@stanford.edu.
² Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: Ayman.jubran@gmail.com.
³ Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: kimjb@stanford.edu.
⁴ Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Department of Clinical Physiology, Karolinska University Hospital, Karolinska Institute, Stockholm. Electronic address: evamaret@gmail.com.
⁵ Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: keganm@stanford.edu.
⁶ Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: fhaddad@stanford.edu.
⁷ Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: mamsalle@stanford.edu.
⁸ Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: mcodari@stanford.edu.
⁹ Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: vhinostr@stanford.edu.
¹⁰ Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: mastro@stanford.edu.
¹¹ Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: anna.karmann@stanford.edu.
¹² Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: yukariko@stanford.edu.
¹³ Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: takeshi24@hotmail.co.jp.
¹⁴ Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: ayeung@stanford.edu.
¹⁵ Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: acwat@stanford.edu.
¹⁶ Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: ansonlee@stanford.edu.
¹⁷ Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: dcm@stanford.edu.
¹⁸ Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: mfischbe@stanford.edu.
¹⁹ Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: wfearon@stanford.edu.
²⁰ Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: M.J.Willemink@stanford.edu.
²¹ Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: d.fleischmann@stanford.edu.

Abstract

Background: Identifying high-risk patients who will not derive substantial survival benefit from TAVR remains challenging. Pulmonary hypertension is a known predictor of poor outcome in patients undergoing TAVR and correlates strongly with pulmonary artery (PA) enlargement on CTA. We sought to evaluate whether PA enlargement, measured on pre-procedural computed tomography angiography (CTA), is associated with 1-year mortality in patients undergoing TAVR.

Methods: We retrospectively included 402 patients undergoing TAVR between July 2012 and March 2016. Clinical parameters, including Society of Thoracic Surgeons (STS) score and right ventricular systolic pressure (RVSP) estimated by transthoracic echocardiography were reviewed. PA dimensions were measured on pre-procedural CTAs. Association between PA enlargement and 1-year mortality was analyzed. Kaplan-Meier and Cox proportional hazards regression analyses were performed.

Results: The median follow-up time was 433 (interquartiles 339-797) days. A total of 56/402 (14%) patients died within 1 year after TAVR. Main PA area (area-MPA) was independently associated with 1-year mortality (hazard ratio per standard deviation equal to 2.04 [95%-confidence interval (CI) 1.48-2.76], p < 0.001). Area under the curve (95%-CI) of the clinical multivariable model including STS-score and RVSP increased slightly from 0.67 (0.59-0.75) to 0.72 (0.72-0.89), p = 0.346 by adding area-MPA. Although the AUC increased, differences were not significant (p = 0.346). Kaplan-Meier analysis showed that mortality was significantly higher in patients with a pre-procedural non-indexed area-MPA of ≥7.40 cm² compared to patients with a smaller area-MPA (mortality 23% vs. 9%; p < 0.001).

Conclusions: Enlargement of MPA on pre-procedural CTA is independently associated with 1-year mortality after TAVR.

Keywords: Aortic valve stenosis; Computed tomography angiography; Pulmonary artery; Pulmonary hypertension; Transcatheter aortic valve replacement.

MeSH terms

Aortic Valve / diagnostic imaging
Aortic Valve / surgery
Aortic Valve Stenosis* / diagnostic imaging
Aortic Valve Stenosis* / surgery
Computed Tomography Angiography
Humans
Kaplan-Meier Estimate
Predictive Value of Tests
Prognosis
Pulmonary Artery / diagnostic imaging
Retrospective Studies
Risk Factors
Severity of Illness Index
Transcatheter Aortic Valve Replacement* / adverse effects
Treatment Outcome

Grants and funding

T32 EB009035/EB/NIBIB NIH HHS/United States