Non-calcific aortic tissue quantified from computed tomography angiography improves diagnosis and prognostication of patients referred for transcatheter aortic valve implantation

Kajetan Grodecki, Balaji K Tamarappoo, Zenon Huczek, Szymon Jedrzejczyk, Sebastien Cadet, Jacek Kwiecinski, Bartosz Rymuza, Radoslaw Parma, Anna Olasinska-Wisniewska, Jadwiga Fijalkowska, Marcin Protasiewicz, Andrzej Walczak, Adrianna Nowak, Radoslaw Gocol, Piotr J Slomka, Krzysztof Reczuch, Dariusz Jagielak, Marek Grygier, Wojciech Wojakowski, Krzysztof J Filipiak, Damini Dey, Kajetan Grodecki, Balaji K Tamarappoo, Zenon Huczek, Szymon Jedrzejczyk, Sebastien Cadet, Jacek Kwiecinski, Bartosz Rymuza, Radoslaw Parma, Anna Olasinska-Wisniewska, Jadwiga Fijalkowska, Marcin Protasiewicz, Andrzej Walczak, Adrianna Nowak, Radoslaw Gocol, Piotr J Slomka, Krzysztof Reczuch, Dariusz Jagielak, Marek Grygier, Wojciech Wojakowski, Krzysztof J Filipiak, Damini Dey

Abstract

Aims: We aimed to investigate the role of aortic valve tissue composition from quantitative cardiac computed tomography angiography (CTA) in patients with severe aortic stenosis (AS) for the differentiation of disease subtypes and prognostication after transcatheter aortic valve implantation (TAVI).

Methods and results: Our study included 447 consecutive AS patients from six high-volume centres reporting to a prospective nationwide registry of TAVI procedures (POL-TAVI), who underwent cardiac CTA before TAVI, and 224 matched controls with normal aortic valves. Components of aortic valve tissue were identified using semi-automated software as calcific and non-calcific. Volumes of each tissue component and composition [(tissue component volume/total tissue volume) × 100%] were quantified. Relationship of aortic valve composition with clinical outcomes post-TAVI was evaluated using Valve Academic Research Consortium (VARC)-2 definitions.High-gradient (HG) AS patients had significantly higher aortic tissue volume compared to low-flow low-gradient (LFLG)-AS (1672.7 vs. 1395.3 mm3, P < 0.001) as well as controls (509.9 mm3, P < 0.001), but increased non-calcific tissue was observed in LFLG compared to HG patients (1063.6 vs. 860.2 mm3, P < 0.001). Predictive value of aortic valve calcium score [area under the curve (AUC) 0.989, 95% confidence interval (CI): 0.981-0.996] for severe AS was improved after addition of non-calcific tissue volume (AUC 0.995, 95% CI: 0.991-0.999, P = 0.011). In the multivariable analysis of clinical and quantitative computed tomography parameters of aortic valve tissue, non-calcific tissue volume [odds ratio (OR) 5.2, 95% CI 1.8-15.4, P = 0.003] and history of stroke (OR 2.6, 95% CI 1.1-6.5, P = 0.037) were independent predictors of 30-day major adverse cardiovascular event (MACE).

Conclusion: Quantitative CTA assessment of aortic valve tissue volume and composition can improve detection of severe AS, differentiation between HG and LFLG-AS in patients referred for TAVI as well as prediction of 30-day MACEs post-TAVI, over the current clinical standard.

Keywords: aortic stenosis; computed tomography angiography; transcatheter aortic valve implantation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.

Figures

Figure 1
Figure 1
Study flowchart.
Figure 2
Figure 2
Workflow for analysis of aortic valve tissue composition. First, region of interest is set between the lower coronary ostium and the virtual basal ring formed by the hinge points of each aortic valve cusp (A and B) and its contours are manually adjusted if necessary (C). Tissue components are identified using HU thresholds as calcific (>650 HU; yellow) or non-calcific (−30 to 350 HU; red) tissues (D and E); and aortic valve is reconstructed in three-dimensional model (F).
Figure 3
Figure 3
Comparison of (A) respective tissue volumes and (B) tissue composition between high-gradient aortic stenosis, low-flow low-gradient (LFLG) aortic stenosis and control groups.
Figure 4
Figure 4
Representative examples of aortic valves for high-gradient, low-flow low-gradient aortic stenoses and control patients captured in non-contrast computed tomography (CT) as well as computed tomography angiography (CTA). Aortic valve calcium score (red in upper panel) was 3022 for high-gradient, 2445 for low-flow low-gradient, and 37 Agatston Units for control patients. Volumes of calcific tissue (yellow in middle and lower panels) were 784, 360, and 44 mm3, respectively. Volumes of non-calcific tissue (red in middle and lower panels) were 875, 1939, and 664 mm3, respectively.
Figure 5
Figure 5
Additive value of non-calcific tissue volume for predicting severe aortic stenosis using different aortic valve calcium measurements: (A) calcium score, (B) calcium score thresholds ≥1274 AU for women and ≥2065 AU for men, (C) calcific tissue volume.
Figure 6
Figure 6
Intraobserver and interobserver repeatability for calcific and non-calcific tissue volumes measurements.

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