Computed tomography angiography-derived extracellular volume fraction predicts early recovery of left ventricular systolic function after transcatheter aortic valve replacement

Donghee Han, Balaji Tamarappoo, Eyal Klein, Jeffrey Tyler, Tarun Chakravarty, Yuka Otaki, Robert Miller, Evann Eisenberg, Rebekah Park, Siddharth Singh, Takahiro Shiota, Robert Siegel, Jasminka Stegic, Tracy Salseth, Wen Cheng, Damini Dey, Louise Thomson, Daniel Berman, Raj Makkar, John Friedman, Donghee Han, Balaji Tamarappoo, Eyal Klein, Jeffrey Tyler, Tarun Chakravarty, Yuka Otaki, Robert Miller, Evann Eisenberg, Rebekah Park, Siddharth Singh, Takahiro Shiota, Robert Siegel, Jasminka Stegic, Tracy Salseth, Wen Cheng, Damini Dey, Louise Thomson, Daniel Berman, Raj Makkar, John Friedman

Abstract

Aims: Recovery of left ventricular ejection fraction (LVEF) after aortic valve replacement has prognostic importance in patients with aortic stenosis (AS). The mechanism by which myocardial fibrosis impacts LVEF recovery in AS is not well characterized. We sought to evaluate the predictive value of extracellular volume fraction (ECV) quantified by cardiac CT angiography (CTA) for LVEF recovery in patients with AS after transcatheter aortic valve replacement (TAVR).

Methods and results: In 109 pre-TAVR patients with LVEF <50% at baseline echocardiography, CTA-derived ECV was calculated as the ratio of change in CT attenuation of the myocardium and the left ventricular (LV) blood pool before and after contrast administration. Early LVEF recovery was defined as an absolute increase of ≥10% in LVEF measured by post-TAVR follow-up echocardiography within 6 months of the procedure. Early LVEF recovery was observed in 39 (36%) patients. The absolute increase in LVEF was 17.6 ± 8.8% in the LVEF recovery group and 0.9 ± 5.9% in the no LVEF recovery group (P < 0.001). ECV was significantly lower in patients with LVEF recovery compared with those without LVEF recovery (29.4 ± 6.1% vs. 33.2 ± 7.7%, respectively, P = 0.009). In multivariable analysis, mean pressure gradient across the aortic valve [odds ratio (OR): 1.07, 95% confidence interval (CI): 1.03-1.11, P: 0.001], LV end-diastolic volume (OR: 0.99, 95% CI: 0.98-0.99, P: 0.035), and ECV (OR: 0.92, 95% CI: 0.86-0.99, P: 0.018) were independent predictors of early LVEF recovery.

Conclusion: Increased myocardial ECV on CTA is associated with impaired LVEF recovery post-TAVR in severe AS patients with impaired LV systolic function.

Keywords: aortic stenosis; computed tomography; extracellular volume; left ventricular function; myocardial fibrosis; transcatheter aortic valve replacement.

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
Case example for ECV Quantification from pre and post contrast ECG-Gated Cardiac CT. Values for CT attenuation in the regions of interest in Hounsfield units are shown. Haematocrit was 36%. Calculated ECV for the septum was (1 − 0.36) × (91 − 43) ÷ (115 − 27) = 35% and for the lateral wall was (1 − 0.36) × (88 − 43) ÷ (115 − 27) = 33%. ECV, extracellular volume fraction.
Figure 2
Figure 2
Histogram of LVEF changes after TAVR. LVEF, left ventricular ejection fraction; TAVR, transcatheter aortic valve replacement.
Figure 3
Figure 3
LVEF changes after TAVR according to ECV derived by CTA. CTA, computed tomography angiography; ECV, extracellular volume fraction; LVEF, left ventricular ejection fraction; TAVR, transcatheter aortic valve replacement.

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