Impact of Right Heart Failure on Outcomes of Transcatheter Aortic Valve Implantation: Insights from the National Inpatient Sample

Background: There are limited data on the impact of right heart failure (RHF) on patients undergoing transcatheter aortic valve implantation (TAVI). We investigated the mortality, in-hospital complications, length of stay, and total hospitalization charges for TAVI admissions, with and without RHF. Methods: We analyzed the National Inpatient Sample data from 2018 to 2022. The International Classification of Diseases-Tenth Revision (ICD-10) codes were used to define the patient cohorts. Propensity score weighting was used to balance patient demographic, hospital-level, and comorbidity data. Results: From 2018 to 2022, there were 383,860 TAVI admissions, among which 1915 (0.50%) had the presence of RHF. Compared to patients without RHF, mortality was higher in patients with RHF (7.57% vs. 1.11%, p < 0.01). Similarly, acute kidney injury (37.10% vs. 8.56%, p < 0.01), respiratory failure (12.79% vs. 1.91%, p < 0.01), and use of mechanical circulatory support (11.48% vs. 0.83%, p < 0.01) was higher in the cohort with RHF. Median length of stay (7 days vs. 2 days, p < 0.01) and hospitalization charges ($257,239 vs. $180,501, p < 0.01) were higher in patients with RHF. Conclusions: In conclusion, we report that RHF is associated with increased mortality risk, complications, and resource utilization in patients undergoing TAVI. Right ventricular function should be a part of the evaluation for TAVI, given significantly elevated risks associated with its presence.

The Current Landscape of Artificial Intelligence in Imaging for Transcatheter Aortic Valve Replacement

Purpose

This review explores the current landscape of AI applications in imaging for TAVR, emphasizing the potential and limitations of these tools for (1) automating the image analysis and reporting process, (2) improving procedural planning, and (3) offering additional insight into post-TAVR outcomes. Finally, the direction of future research necessary to bridge these tools towards clinical integration is discussed.

Recent Findings

Transcatheter aortic valve replacement (TAVR) has become a pivotal treatment option for select patients with severe aortic stenosis, and its indication for use continues to broaden. Noninvasive imaging techniques such as CTA and MRA have become routine for patient selection, preprocedural planning, and predicting the risk of complications. As the current methods for pre-TAVR image analysis are labor-intensive and have significant inter-operator variability, experts are looking towards artificial intelligence (AI) as a potential solution.

Summary

AI has the potential to significantly enhance the planning, execution, and post-procedural follow up of TAVR. While AI tools are promising, the irreplaceable value of nuanced clinical judgment by skilled physician teams must not be overlooked. With continued research, collaboration, and careful implementation, AI can become an integral part in imaging for TAVR, ultimately improving patient care and outcomes.

Letter regarding the article: Trends, and Outcomes of Transcatheter Aortic Valve Implantation in Aortic Insufficiency; A Nationwide Readmission Database Analysis

With great interest, we have read the article "Trends, and Outcomes of Transcatheter Aortic Valve Implantation In Aortic Insufficiency; A Nationwide Readmission Database Analysis" by Ullah et al. For its clarity and conciseness, we applaud the author for his extensive research on this delicate topic. The authors have concisely written several scenarios including the current understanding of trends, and potential outcome of aortic insufficiency following transcatheter aortic valve implantation (TAVI). Nonetheless, we thought it would be helpful to add a few more things to the article's conclusion to strengthen it. The inclusion of the pathophysiology of coronary microcirculation disorder, and endothelial dysfunction in patients with aortic stenosis and then examine the impact of TAVI on these conditions can improve the results. Second, echocardiographic data regarding right and left ventricular dimensions and function or tricuspid regurgitation presence and its severity could lead to a better understanding of the mechanism.

Comparability between Computed Tomography Morphological Vascular Parameters and Echocardiography for the Assessment of Pulmonary Hypertension in Patients with Severe Aortic Valve Stenosis-Results of a Multi-Center Study

Background: Computed tomography (CT) of the aorta and cardiac vessels, which is performed in patients with severe aortic valve stenosis (AS) before transcatheter aortic valve replacement (TAVR), offers the possibility of non-invasive detection of pulmonary hypertension (PH), for example, by determining the diameter of the main pulmonary artery (PA), the right pulmonary artery (RPA) or the left pulmonary artery (LPA). An improvement of the significance of these radiological parameters is often achieved by indexing to the body surface area (BSA). The aim of this study was to compare different echocardiographic systolic pulmonary artery pressure (sPAP) values with radiological data in order to define potential clinical cut-off values for the presence or absence of PH. Methods: A total of 138 patients with severe AS undergoing TAVR underwent pre-interventional transthoracic echocardiography with determination of sPAP values and performance of CT angiography (CTA) of the aorta and femoral arteries. Radiologically, the PA, RPA, LPA, and ascending aorta (AA) diameters were obtained. Vascular diameters were not only indexed to BSA but also ratios were created with AA diameter (for example PA/AA-ratio). From these CT-derived vascular parameters, AUROC curves were obtained regarding the prediction of different sPAP values (sPAP 40−45−50 mmHg) and finally correlation analyses were calculated. Results: The best AUROC and correlation analyses were generally obtained at an sPAP ≥ 40 mmHg. When considering diameters alone, the PA diameter was superior to the RPA and LPA. Indexing to BSA generally increased the diagnostic quality of the parameters, and finally, in a synopsis of all results, PA/BSA had the best AUC 0.741 (95% CI 0.646−0. 836; p < 0.001; YI 0.39; sensitivity 0.87; specificity 0.52) and Spearman’s correlation coefficient (r = 0.408; p < 0.001) at an sPAP of ≥40 mmHg. Conclusions: Features related to pulmonary hypertension are fast and easily measurable on pre-TAVR CT and offer great potential regarding non-invasive detection of pulmonary hypertension in patients with severe AS and can support the echocardiographic diagnosis. In this study, the diameter of the main pulmonary artery with the additionally determined ratios were superior to the values of the right and left pulmonary artery. Additional indexing to body surface area and thus further individualization of the parameters with respect to height and weight can further improve the diagnostic quality.

Impact of Pulmonary Artery Dilatation on Clinical Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVES

The aim of this study was to evaluate the clinical impact of computed tomography (CT)-derived pulmonary artery dilatation (PAD) in patients undergoing transcatheter aortic valve replacement (TAVR).

BACKGROUND

Several studies have reported an association between pulmonary hypertension and cardiovascular events, but the prognostic value of PAD in patients undergoing TAVR remains unclear.

METHODS

The preprocedural computed tomographic studies of patients who underwent TAVR at Cedars-Sinai Medical Center between November 2013 and December 2017 were analyzed. Patients were divided into 2 groups according to the presence of PAD assessed on CT (pulmonary artery [PA] diameter ≥29 mm). The primary endpoint was all-cause mortality at 2 years.

RESULTS

A total of 895 patients were included (mean age 81.3 ± 8.5 years), with a mean Society of Thoracic Surgeons score of 4.8%. The median PA diameter was 28.0 mm, and PAD was observed in 369 patients (41.2%). Compared with the no-PAD group, the PAD group had higher Society of Thoracic Surgeons scores and higher rates of atrial fibrillation, chronic kidney disease, and chronic obstructive pulmonary disease. The PAD group had higher 2-year all-cause mortality than the no-PAD group (28.9% vs 12.8%; P < 0.001), and PAD was independently associated with mortality (adjusted HR: 2.21; 95% CI: 1.44-3.39; P < 0.001). Furthermore, PAD had strong prognostic power in the subgroup analysis, stratified according to PA pressure (>36 mm Hg).

CONCLUSIONS

CT-derived PAD is a significant prognostic factor in patients undergoing TAVR.

Predicting and measuring mortality risk after transcatheter aortic valve replacement

Introduction: Over the last decade, transcatheter aortic valve replacement (TAVR) has emerged as a treatment option for most patients with severe symptomatic aortic stenosis (AS). With growing indications and exponential increase in the number of TAVR procedures, it is important to be able to accurately predict mortality after TAVR.Areas covered: Herein, we review the surgical and TAVR-specific mortality prediction models (MPMs) and their performance in their original derivation and external validation cohorts. We then discuss the role of other important risk assessment tools such as frailty, echocardiographic parameters, and biomarkers in patients, being considered for TAVR.Expert opinion: Conventional surgical MPMs have suboptimal predictive performance and are mis-calibrated when applied to TAVR populations. Although a number of TAVR-specific MPMs have been developed, their utility is also limited by their modest discriminative ability when applied to populations external to their original derivation cohorts. There is an unmet need for robust TAVR MPMs that accurately predict post TAVR mortality. In the interim, heart teams should utilize the currently available TAVR-specific MPMs in conjunction with other prognostic factors, such as frailty, echocardiographic or computed tomography (CT) imaging parameters, and biomarkers for risk assessment of patients, being considered for TAVR.

Radiographic and chest CT imaging presentation and follow-up of COVID-19 pneumonia: a multicenter experience from an endemic area

COVID-19 has infected more than 2 million people in the world in less than 5 months outbreak. Chest imaging is recommended for triage of suspected cases of COVID-19 with moderate-severe clinical features and high pre-test probability of disease, and may help for patient follow-up and to identify patients at higher risk of disease worsening. This pictorial essay illustrates typical and uncommon imaging findings of COVID-19 pneumonia and the role of imaging for patient management.

CT Features and Short-term Prognosis of COVID-19 Pneumonia: A Single-Center Study from Kashan, Iran

PURPOSE

To assess whether certain CT chest features of patients with confirmed coronavirus disease 2019 (COVID-19) may have short-term prognostic value.

MATERIALS AND METHODS

One hundred-twenty consecutive symptomatic patients with COVID-19 infection who had undergone chest CT were enrolled in this retrospective study. Patients were categorized into three groups: routine inward hospitalization, intensive care unit admission, and deceased based on a short-term follow-up. Detailed initial CT features and distributional evaluation were recorded.

RESULTS

The mean age in the deceased group was 70.7 years, significantly higher than the other two groups (P < .05). Ninety-four percent (113/120) of the patients had ground-glass opacities (GGO). Peripheral and lower zone predilection was present in most patients. Subpleural sparing and pleural effusion were seen in approximately 23% (28/120) and 17% (20/120) of the patients, respectively. The combined intensive care unit group and deceased patients had significantly more consolidation, air bronchograms, crazy paving, and central involvement of the lungs compared with routinely hospitalized patients (all P < .05).

CONCLUSION

This study supports the previously described typical CT appearance of COVID-19 pneumonia with bilateral GGO, in peripheral distribution and lower lung zone predilection. Subpleural sparing and pleural effusion were seen approximately in one-fifth and one-sixth of the patients with COVID-19, respectively. Consolidation, air bronchograms, central lung involvement, crazy paving and pleural effusion on initial CT chest have potential prognostic values, the features more commonly observed in critically ill patients.© RSNA, 2020.