Reduced Pulmonary Artery Distensibility Predicts Persistent Pulmonary Hypertension and 2-Year Mortality in Patients with Severe Aortic Stenosis Undergoing TAVR

Valery Turner; Eva Maret; Juyong B Kim; Marina Codari; Virginia Hinostroza; Domenico Mastrodicasa; A Claire Watkins; William F Fearon; Michael P Fischbein; Francois Haddad; Martin J Willemink; Dominik Fleischmann

doi:10.1016/j.acra.2023.03.014

Reduced Pulmonary Artery Distensibility Predicts Persistent Pulmonary Hypertension and 2-Year Mortality in Patients with Severe Aortic Stenosis Undergoing TAVR

Acad Radiol. 2023 Dec;30(12):2825-2833. doi: 10.1016/j.acra.2023.03.014. Epub 2023 May 4.

Authors

Affiliations

¹ Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304. Electronic address: vturner@stanford.edu.
² Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304; Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden.
³ Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California.
⁴ Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304.
⁵ Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California.
⁶ Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California.
⁷ Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California.
⁸ Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California.

PMID: 37147161
DOI: 10.1016/j.acra.2023.03.014

Abstract

Rationale and objectives: Post-TAVR persistent pulmonary hypertension (PH) is a better predictor of poor outcome than pre-TAVR PH. In this longitudinal study we sought to evaluate whether pulmonary artery (distensibility (D_PA) measured on preprocedural ECG-gated CTA is associated with persistent-PH and 2-year mortality after TAVR.

Materials and methods: Three hundred and thirty-six patients undergoing TAVR between July 2012 and March 2016 were retrospectively included and followed for all-cause mortality until November 2017. All patients underwent retrospectively ECG-gated CTA prior to TAVR. Main pulmonary artery (MPA) area was measured in systole and in diastole. D_PA was calculated as: [(area-MPA_max-area-MPA_min)/area-MPA_max]%. ROC analysis was performed to assess the AUC for persistent-PH. Youden Index was used to determine the optimal threshold of D_PA for persistent-PH. Two groups were compared based on a D_PA threshold of 8% (specificity of 70% for persistent-PH). Kaplan-Meier, Cox proportional-hazard, and logistic regression analyses were performed. The primary clinical endpoint was defined as persistent-PH post-TAVR. The secondary endpoint was defined as all-cause mortality 2 years after TAVR.

Results: Median follow-up time was 413 (interquartiles 339-757) days. A total of 183 (54%) had persistent-PH and 68 (20%) patients died within 2-years after TAVR. Patients with D_PA<8% had significantly more persistent-PH (67% vs 47%, p<0.001) and 2-year deaths (28% vs 15%, p=0.006), compared to patients with D_PA>8%. Adjusted multivariable regression analyses showed that D_PA<8% was independently associated with persistent-PH (OR 2.10 [95%-CI 1.3-4.5], p=0.007) and 2-year mortality (HR 2.91 [95%-CI 1.5-5.8], p=0.002). Kaplan-Meier analysis showed that 2-year mortality of patients with D_PA<8% was significantly higher compared to patients with D_PA≥8% (mortality 28% vs 15%; log-rank p=0.003).

Conclusion: D_PA on preprocedural CTA is independently associated with persistent-PH and two-year mortality in patients who undergo TAVR.

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

MeSH terms

Aortic Valve
Aortic Valve Stenosis* / complications
Aortic Valve Stenosis* / diagnostic imaging
Aortic Valve Stenosis* / surgery
Humans
Hypertension, Pulmonary* / complications
Hypertension, Pulmonary* / diagnostic imaging
Longitudinal Studies
Pulmonary Artery / diagnostic imaging
Retrospective Studies
Risk Factors
Severity of Illness Index
Transcatheter Aortic Valve Replacement*
Treatment Outcome

Grants and funding

R38 HL143615/HL/NHLBI NIH HHS/United States