Refai Showkathali (Department of Cardiology, King’s College Hospital, London, UK) and others report in EuroIntervention that patients with incidental findings on computed tomography (CT) aortogram who are undergoing assessment for possible transcatheter aortic valve implantation (TAVI) are significantly less likely to receive TAVI as definitive therapy, have a significantly longer time before undergoing a TAVI procedure, and have worse overall outcomes compared with patients without incidental findings.
Showkathali et al explain that “incidental findings” on CT aortogram in patients undergoing assessment for TAVI are pathologies that are “not directly relevant to the TAVI procedure but may have an important impact on the decision-making process”. They add that such findings are common in TAVI patients and, during heart team discussions, “often complicate other straightforward case reviews”. The aim of the present study was to characterise “the clinical course and outcomes of patients who had incidental CT aortogram findings and to compare them to those patients in whom no such findings were apparent.”
Showkathali et al conducted a retrospective review of 295 patients who underwent CT aortogram at their centre for TAVI assessment between August 2007 and October 2012. They found that 201 patients did have incidental findings, which included 87 patients with at least one finding that was of “immediate clinical significance”. The authors comment that fewer patients with incidental findings of immediate clinical significance eventually underwent TAVI compared with patients with no incidental findings (52.9% of 87 vs. 63% of 94). They add: “It is also important to note that 35% of patients who had immediate clinical significance incidence findings (30 of 87) were deemed not suitable for TAVI due to the finding itself. These patients’ symptoms did not relate to the finding prior to undergoing the scan and the diagnosis would not have been made unless they had their TAVI work-up investigations.” Furthermore, the time interval between CT aortogram and TAVI procedure was longer in patients with incidental findings of immediate clinical significance than in all other patients undergoing TAVI (including those with incidental findings that were not of immediate clinical significance)—96 days vs. 81 days respectively.
The authors also found that the one-year mortality rate was higher in patients with incidental findings of immediate clinical significance compared with all other patients, but not to a significant extent (37.9% vs. 27.4%, respectively; p=0.1). However at the whole follow-up point (21 months), the difference in mortality between these groups was significance (p=0.04 for the comparison). When reviewing the one-year morality rate in the patients who underwent TAVI, the authors did not find any significant differences between patients with incidental findings of immediate clinical significance and patients without such findings. However, they note: “At the latest median follow-up period of 21 months, there was a trend towards increased mortality in patients who had an immediate clinical significance incidental findings who underwent TAVI (after further assessment) when compared with all others who underwent TAVI (34.8% vs. 21.4%; p=0.07).”
Showkathali et al conclude: “Such findings are clearly important for case selection and heart team discussion and should be taken into account when designing, supervising, and auditing a contemporary TAVI service.”
Study author Philip MacCarthy (Department of Cardiology, King’s College Hospital, London, UK) told Cardiovascular News: “Incidental findings during TAVI work up are a very real issue and need to be understood and factored in to the whole TAVI system. It is not surprising that sophisticated scans (such as CT aortograms) identify incidental pathology in elderly patients but when such pathology is found, we need to know what to do with it and recognise that the index procedure (ie. TAVI) and its outcome may be affected.”