Two-year survival of patients screened for transcatheter aortic valve replacement with potentially malignant incidental findings in initial body computed tomography

Transcatheter aortic valve intervention in patients with cancer

The prevalence of concurrent cancer and severe aortic stenosis (AS) is increasing due to an ageing population. In addition to shared traditional risk factors for AS and cancer, patients with cancer may be at increased risk for AS due to off-target effects of cancer-related therapy, such as mediastinal radiation therapy (XRT), as well as shared non-traditional pathophysiological mechanisms. Compared with surgical aortic valve replacement, major adverse events are generally lower in patients with cancer undergoing transcatheter aortic valve intervention (TAVI), especially in those with history of mediastinal XRT. Similar procedural and short-to-intermediate TAVI outcomes have been observed in patients with cancer as compared with no cancer, whereas long-term outcomes are dependent on cancer survival. Considerable heterogeneity exists between cancer subtypes and stage, with worse outcomes observed in those with active and advanced-stage disease as well as specific cancer subtypes. Procedural management in patients with cancer poses unique challenges and thus requires periprocedural expertise and close collaboration with the referring oncology team. The decision to ultimately pursue TAVI involves a multidisciplinary and holistic approach in assessing the appropriateness of intervention. Further clinical trial and registry studies are needed to better appreciate outcomes in this population.

Prognosis of patients with active cancer undergoing transcatheter aortic valve implantation: An insight from Japanese multicenter registry

Background

Malignancy is common in older adults undergoing transcatheter aortic valve implantation (TAVI), and may affect prognosis. The present study aimed to examine whether active cancer affects all-cause mortality rates among patients undergoing TAVI.

Methods

This retrospective study examined data from 1,114 consecutive patients treated between April 2010 and June 2019. Patients with life expectancy of <1 year due to non-cardiac causes were excluded.

Results

Active cancer was defined as cancer under treatment or cured within 1 year, and was recognized in 62 patients (5.6%) with (n = 17) and without (n = 45) metastases. In multivariate analysis, being female (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.39–0.77, p < 0.001), body mass index (BMI) (HR = 0.92 per 1 kg/m² increase, 95% CI 0.87–0.97, p = 0.001), New York Heart Association (NYHA) class III/IV (HR = 1.53, 95% CI 1.06–2.20, p = 0.022), atrial fibrillation (HR = 2.40, 95% CI 1.70–3.38, p < 0.001), albumin levels (HR = 0.41 per 1-g/dl, 95% CI 0.30–0.57, p < 0.001), and cancer metastasis (HR = 5.28, 95% CI 1.86–14.9, p = 0.001) were associated with all-cause mortality after TAVI.

Conclusion

In patients undergoing TAVI, being female, high BMI, NYHA class III/IV, atrial fibrillation, albumin levels, and cancer metastasis were factors associated with mortality. Meanwhile, active cancer without metastasis was not associated with increased mortality rates. These findings would help clinical decision-making by patients and physicians.

Clinical trial registration: UMIN000031133.

Diagnostic Work-Up of the Aortic Patient: An Integrated Approach toward the Best Therapeutic Option

Aortic stenosis (AS) is the most common valvular heart disease. In the last decade, transcatheter aortic valve implantation (TAVI) has become the standard of care for symptomatic patients at high surgical risk. Recently, indications to TAVI have also been extended to the low surgical risk and intermediate surgical risk populations. Consequently, in this setting, some aspects acquire greater relevance: surgical risk evaluation, clinical assessment, multimodality imaging of the valve, and management of coronary artery disease. Moreover, future issues such as coronary artery re-access and valve-in-valve interventions should be considered in the valve selection process. This review aims to summarize the principal aspects of a multidimensional (multidisciplinary) and comprehensive preprocedural work-up. The Heart Team is at the center of the decision-making process of the management of aortic valve disease and bears responsibility for offering each patient a tailored approach based on an individual evaluation of technical aspects together with the risks and benefits of each modality. Considering the progressive expansion in TAVI indication and technological progress, the role of a work-up and multidisciplinary Heart Team will be even more relevant.

Incidental findings on computed tomography for preoperative assessment before transcatheter aortic valve implantation in Japanese patients

Extra-cardiovascular incidental findings (IFs) on preoperative computed tomography (CT) are frequently observed in transcatheter aortic valve implantation (TAVI) candidates. However, the backgrounds of TAVI candidates and comorbidities differ based on the race and/or country, and data on IFs in a specific population are not always applicable to another. The aim of this study was to assess the prevalence, type, and clinical impact of IFs in Japanese TAVI candidates. This was a retrospective, single-center, observational study. CT reports of 257 TAVI candidates were reviewed, and IFs were classified as (a) insignificant: findings that did not require further investigation, treatment, or follow-up; (b) intermediate: findings that needed to be followed up or were considered for further investigation but did not affect the planning of TAVI; and (c) significant: findings that required further investigation immediately or affected the planning of TAVI. At least one IF was found in 254 patients (98.8%). Insignificant, intermediate, and significant IFs were found in 253 (98.4%), 153 (59.5%), and 34 (13.2%) patients, respectively. Newly indicated significant IFs were found in 19 patients (7.4%). In 2 patients (0.8%), TAVI was canceled because of significant IFs. In patients who consequently underwent TAVI, the presence of significant IFs was not associated with the duration from CT performance to TAVI [28 (19-40) days vs. 27 (19-43) days, p = 0.74] and all-cause mortality during the median follow-up period of 413 (223-805) days (p = 0.44). Almost all Japanese TAVI candidates had at least one IF, and the prevalence of significant IFs was not negligible. Although the presence of significant IFs was not associated with mid-term mortality, appropriate management of IFs was considered important.

Aortic valve stenosis and cancer: a common and complex association

Introduction. The prevalence of aortic valve stenosis (AS) and malignancy are both high, especially in elderly people and in developed countries. These two conditions frequently coexist and share the same risk factors as atherosclerotic disease.Area covered. The progression of calcified AS may be accelerated by both cardiovascular risk factors and cancer treatments, such as radiotherapy. The standard treatment for symptomatic severe AS is surgical aortic valve replacement; however, in cancer patients, transcatheter implantation may be preferred as they are often at high-risk for cardiac surgery. In patients with AS and cancer, physicians may face difficult treatment decisions.To date, there is limited information on the impact of malignancy on outcomes in patients with severe AS; hence, there is no established treatment policy.Expert Opinion. Treating clinicians must integrate complex information about the severity of valve disease and expected cardiac outcomes with information regarding the cancer prognosis and the need for specific treatment, including surgery. Other comorbidities, age and frailty also contribute to decision-making about whether, when, and how to perform aortic valve replacement.

Transcatheter aortic valve replacement in patients with a history of cancer: Periprocedural and long-term outcomes

BACKGROUND

A history of cancer is incorporated into the surgical risk assessment of patients undergoing surgical aortic valve replacement through the Society for Thoracic Surgeons score. However, the prognostic significance of cancer in patients treated with transcatheter aortic valve replacement (TAVR) is unclear. As the cancer survivorship population increases, it is imperative to establish the efficacy and safety of TAVR in patients with severe symptomatic aortic stenosis (AS) and a history of malignancy.

OBJECTIVES

The primary goal of this study was to assess the periprocedural outcomes and long-term mortality in patients with a history of cancer undergoing TAVR.

METHODS

A systematic review of PubMed, MEDLINE, and EMBASE was conducted to identify studies reporting outcomes in patients with a history of malignancy undergoing TAVR. A meta-analysis was performed using a random-effects model with a primary outcome of all-cause mortality and cardiac mortality at the longest follow-up. On secondary analyses, procedural safety was assessed.

RESULTS

A total of 13 observational studies with 10,916 patients were identified in the systematic review. Seven studies including 6,323 patients were included in the quantitative analysis. Short-term mortality (relative risk [RR] 0.61, 95%CI 0.36-1.01; p = .06) and long-term all-cause mortality (RR 1.24, 95%CI 0.95-1.63; p = .11) were not significantly different when comparing patients with and without a history of cancer. No significant difference in the rate of periprocedural complications including stroke, bleeding, acute kidney injury, and pacemaker implantation was noted.

CONCLUSION

In patients with severe AS undergoing TAVR, a history of cancer was not associated with adverse short or long-term survival. Based on these findings, TAVR should be considered in all patients with severe symptomatic AS, irrespective of their history of malignancy.

Clinical significance of incidental findings on coronary CT angiography: Insights from a randomized controlled trial

BACKGROUND

The effect of incidental findings from coronary computed tomography angiography (CCTA) on management has not been rigorously investigated. This study uses a control group to explore this relationship.

METHODS

Analysis of data from a randomized controlled trial of acute chest pain patients admitted to telemetry was performed. Patients were randomized to undergo either CCTA (n = 200) or radionuclide myocardial perfusion imaging (MPI) (n = 200). Incidental findings were determined from imaging reports. Records were reviewed to determine subsequent management and imaging during and after hospitalization. Comparisons were performed using Fischer's exact tests.

RESULTS

386 incidental findings were found among 187 CCTA studies. No extra-cardiac incidental findings were noted in the MPI arm, which served as an effective control group. There were significantly more non-coronary medical workups during admission in the CCTA group compared to the MPI group [20% (39) vs. 12% (23), P = 0.038]. CCTA patients underwent significantly more resting echocardiography during the inpatient workup compared to the MPI group [38% (75) vs. 18% (55), P = 0.042]. CCTA patients underwent significantly more non-contrast chest CT exams in the year following admission compared to MPI patients [14% (27) vs. 7% (13) P = 0.029].

CONCLUSIONS

Incidental findings on inpatient CCTAs performed for chest pain have a significant impact on treatment and imaging during and following hospital admission.

Outcomes of Patients Undergoing Transcatheter Aortic Valve Implantation With Incidentally Discovered Masses on Computed Tomography

Routine preprocedural chest and abdomen computed tomography is done prior to transcatheter aortic valve implantation (TAVI), which, in turn, have led to the discovery of radiographic potentially malignant incidental masses (pMIM). It is largely unknown whether pMIM impact the outcomes of patients undergoing TAVI. In this retrospective cohort study from a single center, 1,081 patients underwent TAVI from 2012 to 2016, who had available computed tomographies, survived the index hospitalization, and also had 1 year follow-up data for review. Machine learning (backward propagation neural network)-augmented multivariable regression for mortality by pMIM was conducted. In this cohort of 1,081 patients, the mean age was 79.1 (± 9.0), 48.8% were females, 16.8% had a history of prior malignancy, and 21.1% had pMIM. One-year mortality for the entire cohort was 12.6%. The most common prior malignancies were prostate, breast, and lymphoma and the most common pMIM were present in the lung, kidneys, and thyroid. In a fully adjusted regression analysis, neither prior malignancy nor pMIM increased mortality odds. However, having both was associated with a higher 1-year mortality (odds ratio 4.02, 95% confidence interval 1.50 to 10.73, p = 0.006). In conclusion, presence of pMIM alone was not associated with an increased 1-year mortality among patients undergoing TAVI. However, the presence of pMIM and a history of prior malignancy was associated with a significant increase in 1-year mortality.

Impact of Preprocedural Aortic Valve Calcification on Conduction Disturbances after Transfemoral Aortic Valve Replacement

AIM

The present study analyzes in depth the impact of different calcification patterns on disturbances of the conduction system in transcatheter aortic valve replacement (TAVR) patients.

METHODS AND RESULTS

A total of 169 preprocedural TAVR multislice computed tomography scans from consecutive transfemoral (TF) TAVRs performed between 2014 and 2017 using either Edwards SAPIEN or Medtronic Evolut R valves were retrospectively evaluated. The volume, distribution, and orientation of annular and valvular aortic valve calcification were measured and their impact on postoperative conduction disturbances was determined using linear and logistic regression analyses. The total volume of calcification and distribution at the aortic annulus or valve did not influence the conduction system. Oval calcification of the left aortic cusp was independently associated with an elevated risk for an increase in atrioventricular block degree (+0.6, p = 0.03). Moreover, orthogonal calcifications at the level of the aortic annulus were associated with an increased risk for QRS prolongation (+26 ms, p = 0.004) and an increased risk for permanent pacemaker implantation (OR 4.3, p = 0.03) after TF TAVR. This was more pronounced in patients undergoing TF TAVR using a balloon-expandable Edwards SAPIEN 3 valve (QRS +38.195 ms, p < 0.001; OR permanent pacemaker 15.48, p = 0.013).

CONCLUSION

Orthogonal annular calcification confers an increased risk for conduction disturbances after TAVR. This is even more pronounced after implantation of balloon-expandable valves.

CT in planning transcatheter aortic valve implantation procedures and risk assessment

For surgical aortic valve replacement, the Society of Thoracic Surgeons score (STSS) is the reference standard for the prediction of operative risk. In transcatheter aortic valve implantation (TAVI) though, where the procedure itself is minimally invasive, the traditional risk assessment is supplemented by CTA. Through a consistent approach to the acquisition of high-quality images and the standardised reporting of annular measurements and adverse root and vascular features, patients at risk of complications can be identified. In turn, this may allow for a personalised procedural approach and treatment strategies devised to potentially reduce or mitigate this risk. This article provides a systematic and standardised approach to pre-procedural work-up with computed tomography angiography (CTA) and explores the current state of evidence and future areas of development in this rapidly developing field.

Frequency and impact of incidental findings on computed tomography during work-up for transcatheter aortic valve implantation: single centre experience and review of the literature

OBJECTIVE

To assess the frequency and impact of incidental findings (IF) on CT during work-up for transcatheter aortic valve intervention (TAVI).

METHODS

A consecutive cohort of patients referred for consideration of TAVI who underwent a CT scan between 2009 and 2018 were studied retrospectively. CT reports were reviewed for the presence of IFs and categorised based upon their clinical significance: (a) insignificant-findings that did not require specific treatment or follow-up; (b) intermediate-findings that did not impact on the decision-making process but required follow-up; (c) significant-findings that either required urgent investigation or meant that TAVI was clinically inappropriate.

RESULTS

A total of 652 patients were included, whose median age was 82 years. One or more insignificant IF was found in 95.6% of patients. Intermediate IFs were documented in 5.4%. 91 (14%) patients had at least one significant IF. These included possible malignancy in 67 (74%). The ultimate decision to offer aortic valve intervention was only changed by the presence of an IF in 3.5% of cases.

CONCLUSION

Clinically significant IFs are detected in more than 1 in 10 of patients undergoing CT as part of a TAVI work-up, although just over half of these patients still receive aortic valve intervention.

ADVANCES IN KNOWLEDGE

This study is the largest UK cohort, which, when combined with a review of existing literature, provides a clear picture of the frequency and clinical impact of IFs found at CT for TAVI assessment.

Incidental thoracic findings in computed tomography scans before transcatheter aortic valve implantation

OBJECTIVES

Preoperative computed tomography (CT) scans for transcatheter aortic valve implantation (TAVI) are used routinely. In elderly high-risk patients, incidental radiographic findings are frequently reported. The aim of this study was to investigate the impact of auxiliary findings on the patients' mid-term survival, which might affect the treatment strategy.

METHODS

Between March 2011 and April 2016, all radiological reports of contrast-enhanced CT scans of 976 patients scheduled for TAVI were analysed retrospectively for incidental thoracic findings including solitary pulmonary nodules (SPN) and thoracic lymphadenopathy (LAP). The minimum follow-up period was 1 year after TAVI.

RESULTS

The median age of all patients was 79 years; 51.9% (n = 507) were women. Approximately 37% (n = 361) of patients showed 1 of the determined findings. An SPN ≥5 mm was diagnosed in 16.4% (n = 160) of patients. Four of them developed lung cancer and 2 nodules were identified as metastases during follow-up. In addition, 12% (n = 117) of the patients had thoracic LAP. Whereas SPN had no significant effect on the overall survival rate, evidence of LAP turned out to be a statistically significant factor regarding 4-year survival (P = 0.001; hazard ratio 1.66; 95% confidence internal 1.19-2.31).

CONCLUSIONS

SPN ≥5 mm were detected in 16.4% of patients scheduled for TAVI. Nevertheless, the incidence of lung cancer was low and the effect on survival in this high-risk group of patients was statistically not significant. In contrast, thoracic LAP had a significant negative effect on survival. It needs to be proven if the outcome of this cohort can be enhanced by further diagnostics and therapy.

Outcomes of incidental findings on multi-detector computed tomography for transcatheter aortic valve implantation assessment: A single-centre study and review of the literature

INTRODUCTION

Patients with severe aortic stenosis (AS) require multi-detector computed tomography (MDCT) when considered for transcatheter aortic valve implantation (TAVI). Incidental findings on MDCT are common given the age group and region imaged. Our aim was to evaluate the frequency and outcome of incidental findings (IF) identified on MDCT and the impact on survival.

METHODS

This single-centre analysis retrospectively reviewed severe AS patients who underwent MDCT during TAVI workup. MDCT reports were reviewed for any IF and defined into three categories: IF of no relevant clinical significance (IF-NoCS), IF of non-immediate clinical significance (IF-NICS) and IF of immediate clinical significance (IF-ICS). Demographics, follow-up of IF and survival were calculated from MDCT date.

RESULTS

Two hundred and sixty-five patients underwent MDCT for TAVI suitability (mean age 83 ± 6 years, 52% male). The majority proceeded to TAVI (65%). Renal lesions (25%) and lung nodules (18%) were the most common IF. Fifty-nine patients (22%) had IF-NICS; 39% (23/59) were benign, 59% were not further investigated and one patient had suspected lung cancer. Six patients (2.3%) had IF-ICS and all were diagnosed with lung cancer. During a median follow-up of 272 days, there was no survival difference between patients with IF-ICS or IF-NICS versus patients without IF or IF-NoCS in the overall cohort (P = 0.44) or in TAVI patients (P = 0.88).

CONCLUSION

Incidental findings on MDCT are common with one-quarter having IF-ICS or IF-NCIS. Most patients with IF-NICS did not undergo further investigation. Standardized reporting of MDCT may assist in clarifying the need for further investigation which will in turn influence decision and timing to proceed with TAVI.

Incidental Non-cardiac Findings in Cardiovascular Imaging

Improvements in imaging techniques have led to an expansion in the number of cross-sectional cardiac studies being performed. This means that incidental non-cardiac findings (INCF) identified on cardiac imaging have become an important clinical concern. The majority of INCF are not clinically significant. However, some INCF will require follow-up or changes in management. Differentiating clinically significant from non-significant INCF can be challenging, particularly given the breadth of potential findings and the range of organ systems involved. Following up INCF also has economic implications. Recent changes to the lung nodule follow-up guidelines will reduce the cost of following up incidental lung nodules. In this manuscript, we discuss the common and important INCF which may be identified in cardiovascular imaging and explore potential implications of these findings.

Prognostic impact of myocardial perfusion single photon emission computed tomography in patients with major extracardiac findings by computed tomography for attenuation correction

BACKGROUND

Attenuation correction computed tomography (CT) contributes to an improvement in the diagnostic accuracy of myocardial perfusion imaging (MPI) by single photon emission tomography (SPECT). The aim of this study was to explore the prognosis of patients with major findings by CT according to the results of MPI.

METHODS AND RESULTS

1506 patients who underwent MPI by SPECT were retrospectively included. Attenuation correction CT images were systematically analyzed for major and minor abnormalities. 830 (55.1%) and 212 (14.1%) patients had minor and major extracardiac findings, respectively. Among patients with major extracardiac findings, the abnormality was previously unknown in 113 (53.3%) patients. 90 (41.9%) had abnormal MPI, 73 (34.4%) had a myocardial infarction scar, 55 (25.9%) had myocardial ischemia, and 38 (17.7%) patients had both myocardial infarction scar and myocardial ischemia. Among the 201 patients available for survival analysis, there were 67 (31.2%) deaths over a follow-up period of 3.2±1.3 years. There was no significant impact on survival arising from MPI, whatever the result. The results were the same among the 103 patients with previously unknown major extracardiac findings.

CONCLUSION

Extracardiac findings by CT during MPI are frequent. Patients with major extracardiac findings have a poor mid-term outcome, whatever the results of the myocardial perfusion imaging. Extracardiac findings should be systematically checked when attenuation correction CT is performed.

Incidental abnormal CT scan findings during transcatheter aortic valve implantation assessment: incidence and implications

Objectives

The aim of this retrospective series is to describe the prevalence and clinical significance of the incidental findings found during pre–transcatheter aortic valve implantation (TAVI) work-up and to ascertain the clinical course of such patients.

Methods

Consecutive patients undergoing TAVI from 2013 to 2015 where a TAVI CT assessment was performed (n=138) were included in the study. All incidental findings that were not expected from the patient’s history were discussed at the TAVI multidisciplinary meeting in order to ascertain the clinical significance of said findings and whether they would alter the proposed course of treatment. Mortality data were determined by careful retrospective case note and follow-up appointment analysis.

Results

Seventy-eight patients (57%) were found to have incidental findings on pre-TAVI CT scan. The majority of patients had benign pathology with high incidence in particular of diverticular disease, pleural effusions, gallstones, hiatus hernia and degenerative spinal disease. Vascular pathology such as superior mesenteric, renal and iliac artery stenoses and abdominal aortic aneurysm was detected in seven patients. In terms of long-term mortality data, we found no significant difference between those with incidental findings and those without (p=0.48). Survival as assessed by Kaplan-Meier analysis showed no significant difference between those with and without incidental abnormal CT scan findings (p=0.98).

Conclusions

Incidental findings with potential for malignancy are common in an elderly, comorbid population. Ultimately, clinical correlation and prognosis must be swiftly ascertained in order to streamline the patients down the appropriate management pathway while avoiding unnecessary delay for treatment of their aortic stenosis.

Malignant disease as a comorbidity in patients with severe aortic stenosis: clinical presentation, outcomes, and management

Aim

To investigate the effect of malignancy on the outcomes of patients with severe aortic stenosis (AS) and the management strategy for AS with malignancy.

Methods and results

Using data of 3815 patients with severe AS in a retrospective multicentre registry [CURRENT AS (Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis) registry], we compared 3-year clinical outcomes among three groups based on malignancy status: with malignancy currently under treatment including best supportive care (malignancy group), with a history of malignancy without any current treatment (past history group), or without history of malignancy (no malignancy group). Patients in the malignancy group (n = 124) were more often men and had higher prevalence of low body mass index, recurrence of malignancy, anaemia, and asymptomatic status, despite comparable surgical risks and echocardiographic parameters. The malignancy group or the past history group (n = 389) had significantly higher risk for all-cause death [hazard ratio (HR) 2.49, 95% CI (95% confidence interval) 1.98-3.14; HR 1.23, 95% CI 1.04-1.46] and for malignancy-related death (HR 16.2, 95% CI 10.64-24.54; HR 3.66, 95% CI 2.43-5.52) than that of the no malignancy group (n = 3302). The excess risk for aortic valve-related death was not observed in the malignancy group (HR 0.79, 95% CI 0.48-1.29) and was lower in the past history group (HR 0.72, 95% CI 0.53-0.96). In the malignancy group, the treatment strategy (surgery: n = 16, conservative management: n = 108) was determined based on the clinical status of AS or life expectancy.

Conclusions

Malignancy had marked effect on all-cause death and malignancy-related death in patients with severe AS. History of malignancy also had a smaller but significant effect on mortality.

Incidental findings in multislice computed tomography prior to transcatheter aortic valve implantation: frequency, clinical relevance and outcome

Multislice computed tomography (MSCT) has emerged as the mainstay in patients planned for transcatheter aortic valve implantation (TAVI). Incidental findings (IF) in MSCT are common. However, the exact incidence, clinical relevance and further consequences of IF are unclear and it is controversial whether IF adversely affect patients' outcome. We analyzed MSCT data of 1050 patients screened for TAVI between January 2011 and December 2014. Median follow-up of patients was 20 months. In total, 3194 IF were identified, which were classified into clinically non-relevant IF (2872, 90%) and clinically relevant IF (322, 10%). In 25% of patients (258/1050) at least one clinically relevant IF was present. Age (80 ± 7 vs. 80 ± 7 years; p = 0.198) and EuroSCORE II (3.6% [2.1-5.7] vs. 3.6% [2.1-5.9]; p = 0.874) was similar between patients with and without a clinically relevant IF. TAVI was performed less frequently in patients with a clinically relevant IF (76% vs. 85%; p < 0.001), with more patients receiving surgical aortic valve replacement in that group (14% vs. 11%; p = 0.042), possibly due to the high rate of incidental aneurysms of the ascending aorta (n = 48). If TAVI was performed mortality did not differ (30-days: 4% vs. 3%; p = 0.339, 1-year: 11% vs. 14%; p = 0.226) between patients with and without a clinically relevant IF. Our study is the largest study to analyze prevalence, clinical relevance and therapeutic consequences of IF during screening for TAVI. IF in pre-procedural MSCT are common and clinically relevant in one-quarter of patients. However, these findings had no impact on overall mortality.

Impact of Potentially Malignant Incidental Findings by Computed Tomographic Angiography on Long-Term Survival After Transcatheter Aortic Valve Implantation

Computed tomography angiography (CTA) in workup for transcatheter aortic valve implantation (TAVI) frequently reveals potentially malignant incidental findings. Most incidental findings provoke discussions on their influence. We aimed to analyze if these findings were a predictor of long-term survival after TAVI. In a single-center retrospective analysis, all consecutive patients with pre-TAVI CTA were included (years 2009 to 2014). Patients were divided by presence or absence of incidental findings. We analyzed up to 5 years of all-cause, non-cardiovascular and cardiovascular mortality for all 553 patients who underwent TAVI; 113 had a potentially malignant incidental finding (20.4%). At 5 years, all-cause mortality risk was 64.5% in patients with versus 49.1% in patients without a finding (hazard ratio [HR] 1.70, 95% confidence interval [CI] 1.25 to 2.31). After adjustment, the findings remained an independent predictor of all-cause (adjusted HR 1.46, 95% CI 1.07 to 1.99) and non-cardiovascular mortality (adjusted subdistribution HR 1.84, 95% CI 1.06 to 3.20), but not of cardiovascular mortality. In conclusion, the presence of potentially malignant incidental findings on CTA is an independent predictor of long-term all-cause and noncardiovascular mortality but not of cardiovascular mortality.

Transcatheter Aortic Valve Replacement: A Review

Patients with inoperable, high-risk, and intermediate-risk aortic stenosis can now be treated with transcatheter aortic valve replacement. Centers for Medicare and Medicaid Services and the Food and Drug Administration selectively choose centers based on experience and require a collaborative, multidisciplinary team approach in the treatment and decision making for these patients. The work-up has been streamlined. Gated multislice computed tomography angiogram has emerged as the gold standard for assessment of valve anatomy and sizing of the transcatheter heart valve. Assessment of risk has evolved to include a more comprehensive functional and frailty evaluation. Long term-results are needed before the expansion of transcatheter aortic valve replacement into the low-risk category.

Two-year post-discharge costs of care among patients treated with transcatheter or surgical aortic valve replacement in Germany

Background

This study presents data on post-discharge costs of care among patients treated with transcatheter or surgical aortic valve replacement over a two year period.

Methods

Based on a prospective clinical trial, post-discharge utilization of health services and status of assistance were collected for 151 elderly patients via 2250 monthly telephone interviews, valued using standardized unit costs and analysed using two-part regression models.

Results

At month 1 post-discharge, total costs of care are substantially elevated (monthly mean: €3506.7) and then remain relatively stable over the following 23 months (monthly mean: €622.3). As expected, the majority of these costs are related to in-hospital care (~98% in month 1 post-discharge and ~72% in months 2–24). Patients that died during follow-up were associated with substantially higher cost estimates of in-hospital care than those surviving the two-year study period, while patients’ age and other patient characteristics were of minor relevance. Estimated costs of outpatient care are lower at month 1 than during the rest of the study period, and not affected by the event of death during follow-up. The estimated costs of nursing care are, in contrast, much higher in year 2 than in year 1 and differ substantially by gender and type of procedure as well as by patients’ age. Overall, these monthly cost estimates add up to €10,352 for the first and €7467.6 for the second year post-discharge.

Conclusions

Substantial cost increases at month 1 post-discharge and in case of death during follow-up are the main findings of the study, which should be taken into account in future economic evaluations on the topic. Application of standardized unit costs in combination with monthly patient interviews allows for a far more precise estimate of the variability in post-discharge health service utilization in this group of patients than the ones given in previous studies.

Trial registration

German Clinical Trial Register Nr. DRKS00000797.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2432-8) contains supplementary material, which is available to authorized users.

Standard imaging techniques in transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) has become a widely accepted therapeutic option for patients with severe, symptomatic aortic stenosis at intermediate, high, or extreme risk for conventional surgery as determined through a heart team approach. Two valve prostheses are currently available and the Food and Drug Administration (FDA) approved in the United States for TAVR: the self-expandable Medtronic CoreValve (Medtronic, Inc., Minneapolis, MN, USA) and the balloon-expandable Edwards Sapien Valve (Edwards Lifesciences, Irvine CA, USA). The preoperative evaluation for TAVR includes transthoracic echocardiography (TTE) for the diagnosis of aortic stenosis. Cardiac computed tomography (CTA) has become the imaging modality of choice for annular sizing. Aortic root dimensions and coronary ostia height, and the degree of annular and left ventricular outflow tract calcification are also assessed to estimate the risk of coronary obstruction, annular rupture, and postoperative aortic regurgitation. Finally, CTA is essential to determine the adequacy of the peripheral vasculature for a transfemoral approach. Intraoperatively, fluoroscopy is mandatory for valve positioning, whereas the use of TTE or transesophageal echocardiography (TEE) varies by center. TTE is used for postoperative surveillance of valve function.

Non-Cardiovascular Computed Tomography Incidental Findings in Patients Who Underwent Transaortic Valve Implantation Procedure

Background

Transcatheter aortic valve implantation (TAVI) is a new treatment option for patients with severe aortic stenosis. Pre-TAVI procedure workup includes computed tomography angiography (CTA) of the heart and aorta from aortic annulus to the iliofemoral arteries. Frequently, there are a number of incidental non-cardiac findings (INCFs) in pre-TAVI CTA. However, the frequency and clinical significance of these INCFs are unknown. The aim of our study was to investigate the prevalence of INCFs and their clinical significance.

Methods

This was a retrospective review of 67 patients who underwent dedicated pre-TAVI CTA from 2010 till 2015. Non-cardiovascular INCFs were classified according to their clinical significance into three categories. The first category includes findings that may require urgent treatment. The second category includes findings that need further follow-up. The third category includes incidental findings that require no further follow-up or recommendation.

Results

The total number of patients was 67, and the mean age was 73 ± 8 years. All patients had INCFs and the total number was 248. Of the patients, 69% had chest findings, 85% had abdominal findings, and 33% had musculoskeletal findings. Results based on categorical classification were as follows: 9%, 25%, and 66% of these 248 findings belong to the first category, the second category, and the third category, respectively.

Conclusion

Non-cardiovascular INCFs are common in pre-TAVI CTA presumably due to increased age of such specific population. These findings have variable clinical significance and some of them might require acute treatment or additional evaluation, and should be managed properly taking into consideration patient’s life expectancy and comorbidities.

Thoracic Malignancies and Pulmonary Nodules in Patients under Evaluation for Transcatheter Aortic Valve Implantation (TAVI): Incidence, Follow Up and Possible Impact on Treatment Decision

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has become the treatment of choice in patients with severe aortic valve stenosis who are not eligible for operative replacement and an alternative for those with high surgical risk. Due to high age and smoking history in a high proportion of TAVI patients, suspicious findings are frequently observed in pre-procedural chest computer tomography (CCT).

METHODS

CCT scans of 484 consecutive patients undergoing TAVI were evaluated for incidentally discovered solitary pulmonary nodules (SPN).

RESULTS

In the entire study population, SPN ≥ 5 mm were found in 87 patients (18%). These patients were compared to 150 patients who were incidentally collected from the 397 patients without SPN or with SPN < 5 mm (control group). After a median follow-up of 455 days, lung cancer was diagnosed in only two patients. Neither SPN ≥ 5 mm (p = 0.579) nor SPN > 8 mm (p = 0.328) were significant predictors of overall survival.

CONCLUSIONS

Despite the high prevalence of SPNs in this single center TAVI cohort lung cancer incidence at midterm follow-up seems to be low. Thus, aggressive diagnostic approaches for incidentally discovered SPN during TAVI evaluation should not delay the treatment of aortic stenosis. Unless advanced thoracic malignancy is obvious, the well documented reduction of morbidity and mortality by TAVI outweighs potentially harmful delays regarding further diagnostics. Standard guideline-approved procedure for SPN can be safely performed after TAVI.

Clinical and economic consequences of non-cardiac incidental findings detected on cardiovascular computed tomography performed prior to transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve implantation (TAVI) is an effective treatment option for patients with severe degenerative aortic valve stenosis who are high risk for conventional surgery. Computed tomography (CT) performed prior to TAVI can detect pathologies that could influence outcomes following the procedure, however the incidence, cost, and clinical impact of incidental findings has not previously been investigated. 279 patients underwent CT; 188 subsequently had TAVI and 91 were declined. Incidental findings were classified as clinically significant (requiring treatment), indeterminate (requiring further assessment), or clinically insignificant. The primary outcome measure was all-cause mortality up to 3 years. Costs incurred by additional investigations resultant to incidental findings were estimated using the UK Department of Health Payment Tariff. Incidental findings were common in both the TAVI and medical therapy cohorts (54.8 vs. 70.3%; P = 0.014). Subsequently, 45 extra investigations were recommended for the TAVI cohort, at an overall average cost of £32.69 per TAVI patient. In a univariate model, survival was significantly associated with the presence of a clinically significant or indeterminate finding (HR 1.61; P = 0.021). However, on multivariate analysis outcomes after TAVI were not influenced by any category of incidental finding. Incidental findings are common on CT scans performed prior to TAVI. However, the total cost involved in investigating these findings is low, and incidental findings do not independently identify patients with poorer outcomes after TAVI. The discovery of an incidental finding on CT should not necessarily influence or delay the decision to perform TAVI.