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CT-Extracellular Volume: a gatekeeper for ATTR-CM screening in severe aortic stenosis?
Session:
Sessão de Comunicações Orais 10 – Estratificação de risco guiada por imagem em situações cardíacas complexas
Speaker:
André Filipe Silva Pereira Martins Lobo
Congress:
CPC 2026
Topic:
B. Imaging
Theme:
17. Myocardial Disease
Subtheme:
17.3 Myocardial Disease – Diagnostic Methods
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Andre Lobo; Carolina Castro; José Cavadas; Mariana Brandão; Marta Catarina Almeida; Rafael Teixeira; Marisa Silva; Pedro Braga; Nuno Dias Ferreira; Francisco Sampaio; Ricardo Fontes-Carvalho
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif">Background: Transthyretin cardiac amyloidosis (ATTR-CM) is a frequent and clinically relevant comorbidity in patients with severe aortic stenosis (AS) but remains markedly underdiagnosed in real-world practice. Extracellular volume (ECV) can be quantified as part of pre-TAVI cardiac computed tomography (CT), having high diagnostic accuracy for ATTR-CM. We aimed to evaluate the feasibility of ATTR-CM screening during pre-TAVI CT evaluation, assess its current implementation, and explore the role of ECV in identifying patients who should proceed to the ATTR-CM diagnostic algorithm per current guidelines.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif">Methods: Retrospective analysis of patients with severe AS undergoing cardiac CT for TAVI planning between April 2024 and April 2025. A standardized 5-minute delayed dual-energy acquisition was used for ECV quantification. Previously validated ECV thresholds (29.2%, 31.4% and 33.4%) were applied to estimate their impact on screening burden and clinical implications.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif">Results: 253 patients were included (median age 81 years; 48.6% male). Median ECV was 30.4%. 80.6% of patients fulfilled criteria for ATTR-CM screening according to current ESC recommendations; however, only 14 patients (5.5%) were screened. ATTR-CM was confirmed in 2 patients (median ECV 45.6%) and excluded in 12. Among patients with a negative amyloidosis work-up, 50% had ECV <29.2%.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif">Using validated ECV cut-offs, eligibility for screening would decrease to 57%, 42%, and 28% with thresholds of 29.2%, 31.4%, and 33.4%, respectively.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif">Higher ECV categories were strongly associated with increased mortality (ECV ≥33.4%: HR 3.65, 95% CI 1.54–8.64, p = 0.003; ECV ≥31.4%: HR 3.57, 95% CI 1.39–9.18, p = 0.008). </span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif">Patients in these categories displayed a phenotype consistent with ATTR-CM. At ECV ≥31.4%, patients showed higher NT-proBNP (2579 vs. 1366 pg/mL, p < 0.001), lower LVEF (50.9% vs. 56.8%, p < 0.001), worse GLS (−12.9% vs. −14.3%, p = 0.047), lower TAPSE (20 vs. 22 mm, p < 0.001), higher prevalence of atrial fibrillation (41.1% vs. 26.7%, p = 0.016), pacemaker implantation (17.8% vs. 8.9%, p = 0.036), and LFLG AS (21.5% vs. 6.8%, p = 0.004). At ECV ≥33.4%, significant differences remained for NT-proBNP, LVEF, TAPSE, pacemaker implantation, and LFLG AS (all p < 0.05).</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif">Conclusions: ATTR-CM remains markedly underdiagnosed in clinical practice. CT-derived ECV, obtainable without additional testing, may substantially refine patient selection for ATTR-CM screening. Routine use in the pre-TAVI setting may improve ATTR-CM detection, which carries prognostic and management implications</span></span></span></p>
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