Original article
Imaging Pandora's Box: Incidental Findings in Elderly Patients Evaluated for Transcatheter Aortic Valve Replacement

https://doi.org/10.1016/j.mayocp.2014.03.011Get rights and content

Abstract

Objective

To determine the frequency and clinical impact of noncardiovascular incidental findings (IFs) detected on preoperative computed tomographic angiography (CTA) of the chest/abdomen/pelvis performed in elderly patients with severe aortic stenosis being considered for transcatheter aortic valve replacement (TAVR).

Patients and Methods

The CTA studies for 424 consecutive patients being evaluated for TAVR between January 1, 2009, through January 24, 2012, were reviewed for noncardiovascular IFs (62.0% male; median ± SD age, 82±8.3 years). The electronic medical record was reviewed to assess for subsequent clinical management and survival.

Results

Potentially pathologic IFs (PPIFs) were present in 285 patients (67.2%). The mean ± SD number of PPIFs per patient was 1.1±1.0 (range, 0-4). Factors associated with higher numbers of PPIFs were reduced ejection fraction (P=.02) and history of smoking (P=.06). Potentially pathologic incidental findings prompted clinical work-up in 39 patients (9.2%) and delayed or canceled treatment plans for aortic stenosis in 7 patients (1.7%). The number needed to image to diagnose a new malignancy or medical condition was 19. The number of PPIFs was predictive of poor overall survival before (hazard ratio, 1.58; 95% CI, 1.31-1.88) and after (hazard ratio, 1.45; 95% CI, 1.19-1.76) adjustment for baseline clinical variables (P<.001 for both).

Conclusion

This investigation found that PPIFs are common in elderly patients undergoing TAVR-CTA scans and, once discovered, commonly generate further clinical evaluation. Higher numbers of PPIFs may be predictive of poorer survival, but further study is required to guide the appropriateness of pursuing diagnostic evaluations for asymptomatic PPIFs in this elderly population.

Section snippets

Patients

The Mayo Clinic Institutional Review Board approved this study. Consecutive patients with severe AS undergoing a TAVR-CTA scan between January 1, 2009, through January 24, 2012, were identified via the Mayo Clinic radiology database. Patients were included in this study if their imaging examination was performed as a part of an evaluation for possible TAVR regardless of whether they ultimately received TAVR, surgical aortic valve replacement (SAVR), or neither.

TAVR-CTA Scan Technique

The scan technique was created to

Patients

During the study, 424 patients underwent TAVR-CTA imaging. The median ± SD age was 82±8.3 years, and 263 patients (62.0%) were male. Intravenous contrast was withheld for medical reasons in 72 patients (17.0%). Table 1 contains information regarding associated clinical parameters and medical comorbidities. After the initial clinical evaluation, 111 patients underwent TAVR (64 transfemoral, 44 transapical, and 3 transaortic), 113 underwent SAVR, and 200 did not undergo either procedure. The mean

Discussion

The novel principal findings of this investigation are as follows: (1) PPIFs are routinely discovered in elderly patients with AS who undergo TAVR-CTA imaging (the number needed to image to diagnose a new cancer or noncancerous medical condition was 19), (2) increasing numbers of PPIFs may be predictive of poorer overall survival, (3) patient factors have been identified that are associated with higher numbers of PPIFs (reduced ejection fraction and smoking history), (4) PPIFs result in

Conclusion

Potentially pathologic incidental findings are common in elderly patients undergoing TAVR-CTA scans and, once discovered, commonly generate further clinical evaluation. Higher numbers of PPIFs may be predictive of poorer survival, but further study is required to guide the appropriateness of pursuing diagnostic evaluations for asymptomatic PPIFs in this elderly population.

Acknowledgments

Statistical analysis was performed in direct consultation and collaboration with the biostatisticians at the Service Center of the Mayo Clinic Translational Science Activities. We thank the biostatisticians for their assistance. We also thank the Rochester Epidemiology Project8 for use of its Minnesota death certificate database and Drs Rajiv Gulati and Daniel B. Spoon for use of the Mayo Clinic percutaneous coronary intervention mortality database.

References (20)

There are more references available in the full text version of this article.

Cited by (16)

  • Prevalence and consequences of noncardiac incidental findings on preprocedural imaging in the workup for transcatheter aortic valve implantation, renal sympathetic denervation, or MitraClip implantation

    2018, American Heart Journal
    Citation Excerpt :

    Instead, renal insufficiency and COPD at baseline appeared to be the sole independent predictors for 1-year mortality. Previous work by Orme et al concluded that a higher number of potentially pathological IF per patient might impact 2-year mortality in 424 patients screened for TAVI.15 In the subgroup of patients from our study that were screened for TAVI (n = 782), we were not able to confirm that the number of moderate or major IF per patient significantly predicts 1-year mortality.

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

    2017, American Journal of Cardiology
    Citation Excerpt :

    To the best of our knowledge, this is the largest study on incidental findings in TAVI work-up with a follow-up of up to 5 years specifically after TAVI. Previous studies published conflicting results on short- and mid-term impact of incidental findings.8–11 In contrast to the current study, these reports focused on evaluation of survival after CTA and not specifically after TAVI.

View all citing articles on Scopus

For editorial comment, see page 715; for related articles, see pages 718, 727, 738

View full text