Extracellular volume fraction (ECV) derived from pre-operative computed tomography predicts prognosis in patients undergoing transcatheter aortic valve implantation (TAVI)

Davide Vignale, Anna Palmisano, Chiara Gnasso, Davide Margonato, Davide Romagnolo, Simone Barbieri, Giacomo Ingallina, Stefano Stella, Marco Bruno Ancona, Matteo Montorfano, Francesco Maisano, Eustachio Agricola, Antonio Esposito, Davide Vignale, Anna Palmisano, Chiara Gnasso, Davide Margonato, Davide Romagnolo, Simone Barbieri, Giacomo Ingallina, Stefano Stella, Marco Bruno Ancona, Matteo Montorfano, Francesco Maisano, Eustachio Agricola, Antonio Esposito

Abstract

Aims: Transcatheter aortic valve implantation (TAVI) is the treatment of choice for high-risk patients with severe aortic stenosis (AS). A portion of TAVI recipients has no long-term clinical benefit, and myocardial fibrosis may contribute to unfavourable outcomes. We aimed to assess the prognostic value of an interstitial fibrosis marker, extracellular volume fraction (ECV), measured at planning computed tomography (CT) before TAVI.

Methods and results: From October 2020 to July 2021, 159 consecutive patients undergoing TAVI planning CT were prospectively enroled. ECV was calculated as the ratio of myocardium and blood pool differential attenuations before and 5 min after contrast administration, pondered for haematocrit. A composite endpoint including heart failure hospitalization (HFH) and death was collected by telehealth or in-person follow-up visits in the 113 patients constituting the final study population. Cox proportional hazards model was used to assess association between ECV and the composite endpoint.Median follow-up was 13 (11-15) months. The composite endpoint occurred in 23/113 (20%) patients. These patients had lower aortic valve mean pressure gradient [39 (29-48) vs. 46 (40-54) mmHg, P = 0.002] and left ventricular and right ventricular ejection fraction [51 (37-69) vs. 66 (54-74)%, P = 0.014; 45 (31-53) vs. 49 (44-55)%, P = 0.010] and higher ECV [31.5 (26.9-34.3) vs. 27.8 (25.3-30.2)%, P = 0.006]. At multivariable Cox analysis, ECV higher than 31.3% was associated to increased risk of death or HFH at follow-up (hazard ratio = 5.92, 95% confidence interval 2.37-14.75, P < 0.001).

Conclusion: In this prospective observational cohort study, ECV measured at TAVI planning CT predicts the composite endpoint (HFH or death) in high-risk severe AS patients.

Keywords: CT; ECV; TAVI; TAVR; aortic stenosis.

Conflict of interest statement

Conflict of interest: None declared.

© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Patient enrollment flowchart. TAVI, transcatheter aortic valve implantation; AVR, aortic valve replacement; AS, aortic stenosis; CT, computed tomography.
Figure 2
Figure 2
ECV measurement in two exemplificative cases. Regions of interest (ROIs) were drawn in the LV blood pool (smaller ROI in white) and in the mid-ventricular septum (larger ROI in yellow) on an axial slice in the late post-contrast scan (B and D) and were then copied on the coregistered pre-contrast scan (A and C). Top row images show the case of an 85-year-old male with an ECV of 37.3% who experienced heart failure hospitalization (HFH) 14 months after TAVI. Bottom row images show the case of a 78-year-old female with an ECV of 25.3% who has not experienced death of HFH 17 months after TAVI.
Figure 3
Figure 3
Correlation scatterplots. Markers of myocardial damage (troponin T) and dysfunction (BNP) showed a stronger direct correlation with the fibrosis mass indexed (A and C, respectively) than with ECV (B and D, respectively). Furthermore, the markers of AS severity, AV calcium score and mean aortic pressure gradient, showed a direct correlation with LV mass indexed (E and G, respectively), while ECV was not correlated (F and H, respectively).
Figure 4
Figure 4
The Kaplan–Meier survival curve of patients stratified according to ECV. Patients with ECV ≥31.3% (lower line in red) experienced more events of death or HFH than patients with ECV P < 0.001.

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