Detection and Prediction of Bioprosthetic Aortic Valve Degeneration

• Published in: Journal of the American College of Cardiology Vol. 73; no. 10; pp. 1107 - 1119
• Main Authors: Cartlidge, Timothy R.G., Doris, Mhairi K., Sellers, Stephanie L., Pawade, Tania A., White, Audrey C., Pessotto, Renzo, Kwiecinski, Jacek, Fletcher, Alison, Alcaide, Carlos, Lucatelli, Christophe, Densem, Cameron, Rudd, James H.F., van Beek, Edwin J.R., Tavares, Adriana, Virmani, Renu, Berman, Daniel, Leipsic, Jonathon A., Newby, David E., Dweck, Marc R.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 19.03.2019; Elsevier Limited; Elsevier Biomedical
• Subjects: Aged; Angiography; Aortic valve; Aortic Valve - physiopathology; Aortic Valve - surgery; Aortic Valve Insufficiency - diagnosis; Aortic Valve Insufficiency - etiology; aortic valve replacement; Aortic Valve Stenosis - diagnosis; Aortic Valve Stenosis - surgery; Bioprosthesis; bioprosthetic valve degeneration; Calcification; Calcinosis - diagnosis; Calcinosis - etiology; Cardiology; Catastrophic failure analysis; Computed tomography; Computed Tomography Angiography - methods; Degeneration; Durability; Echocardiography; Echocardiography - methods; Emission analysis; Female; Fluorides; Fluorine isotopes; Fluorodeoxyglucose F18 - pharmacology; Heart Valve Prosthesis; Heart valves; Histology; Humans; Male; Patients; Population; Positron emission; Positron emission tomography; Positron Emission Tomography Computed Tomography - methods; Postoperative Complications - diagnosis; Postoperative Complications - etiology; Predictive Value of Tests; Prognosis; Prostheses; Prosthesis Failure - adverse effects; Radiopharmaceuticals - pharmacology; Variables; Velocity; United States > US; bioprosthetic valve degeneration; CT; aortic valve replacement; histology; TBR; calcification; positron emission tomography; PET
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2018.12.056

Bioprosthetic aortic valve degeneration is increasingly common, often unheralded, and can have catastrophic consequences. The authors sought to assess whether 18F-fluoride positron emission tomography (PET)-computed tomography (CT) can detect bioprosthetic aortic valve degeneration and predict valve dysfunction. Explanted degenerate bioprosthetic valves were examined ex vivo. Patients with bioprosthetic aortic valves were recruited into 2 cohorts with and without prosthetic valve dysfunction and underwent in vivo contrast-enhanced CT angiography, 18F-fluoride PET, and serial echocardiography during 2 years of follow-up. All ex vivo, degenerate bioprosthetic valves displayed 18F-fluoride PET uptake that colocalized with tissue degeneration on histology. In 71 patients without known bioprosthesis dysfunction, 14 had abnormal leaflet pathology on CT, and 24 demonstrated 18F-fluoride PET uptake (target-to-background ratio 1.55 [interquartile range (IQR): 1.44 to 1.88]). Patients with increased 18F-fluoride uptake exhibited more rapid deterioration in valve function compared with those without (annualized change in peak transvalvular velocity 0.30 [IQR: 0.13 to 0.61] vs. 0.01 [IQR: −0.05 to 0.16] ms−1/year; p < 0.001). Indeed 18F-fluoride uptake correlated with deterioration in all the conventional echocardiographic measures of valve function assessed (e.g., change in peak velocity, r = 0.72; p < 0.001). Each of the 10 patients who developed new overt bioprosthesis dysfunction during follow-up had evidence of 18F-fluoride uptake at baseline (target-to-background ratio 1.89 [IQR: 1.46 to 2.59]). On multivariable analysis, 18F-fluoride uptake was the only independent predictor of future bioprosthetic dysfunction. 18F-fluoride PET-CT identifies subclinical bioprosthetic valve degeneration, providing powerful prediction of subsequent valvular dysfunction and highlighting patients at risk of valve failure. This technique holds major promise in the diagnosis of valvular degeneration and the surveillance of patients with bioprosthetic valves. (18F-Fluoride Assessment of Aortic Bioprosthesis Durability and Outcome [18F-FAABULOUS]; NCT02304276) [Display omitted]