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18F-Fluoride PET-CT in the detection of early bioprosthetic valve degeneration

Session Young Investigator Award Session Valvular Heart Disease

Speaker Timothy Cartlidge

Event : ESC Congress 2018

  • Topic : imaging
  • Sub-topic : Imaging: Valve Disease
  • Session type : Young Investigator Award Abstracts

Authors : T R G Cartlidge (Edinburgh,GB), MK Doris (Edinburgh,GB), S Sellers (Vancouver,CA), EJR Van Beek (Edinburgh,GB), R Virmani (Gaithersburg,US), J Leipsic (Vancouver,CA), DE Newby (Edinburgh,GB), MR Dweck (Edinburgh,GB)

T.R.G. Cartlidge1 , M.K. Doris1 , S. Sellers2 , E.J.R. Van Beek1 , R. Virmani3 , J. Leipsic2 , D.E. Newby1 , M.R. Dweck1 , 1University of Edinburgh, BHF Centre for Cardiovascular Science - Edinburgh - United Kingdom , 2University of British Columbia - Vancouver - Canada , 3CVPath Institute - Gaithersburg - United States of America ,

European Heart Journal ( 2018 ) 39 ( Supplement ), 239

Background: Bioprosthetic valve degeneration is increasingly common, often unheralded and can be catastrophic.

Methods: Degenerate bioprosthetic valves were assessed by micro-positron emission tomography (PET), high resolution micro-computed tomography (CT) and histopathology. Patients were recruited to a clinical study either with end-stage bioprosthetic valve dysfunction (Cohort 1) or without known valve dysfunction (Cohort 2) and underwent contrast-enhanced CT angiography, 18F-fluoride PET and serial echocardiography.

Results: Fifteen degenerate explanted bioprosthetic valves were assessed by micro-PET/CT and all of these valves exhibited significant uptake of 18F-fluoride. Histological analysis demonstrated leaflet calcification in 13 of the 15 valves whilst other important histological features included leaflet thrombosis, fibrosis and severe disruption of collagen architecture. 18F-Fluoride localised to these histological features even in the absence of calcification.

In Cohort 1, all patients with bioprosthetic failure (n=6) exhibited leaflet abnormalities on both CT and PET. In Cohort 2 (1 month (n=9), 2 (n=22), 5 (n=20) and >10 years (n=20) post-valve implantation), 3 subjects had bioprosthetic dysfunction on echocardiography, 13 had valve abnormalities on CT (6 spotty calcification, 4 non-calcific leaflet thickening, 7 pannus) and 27 had increased 18F-fluoride PET uptake (target-to-background ratio [TBRmean] 1.55 [1.47–1.92]). Patients with increased 18F-fluoride uptake demonstrated a >10-fold increase in mean gradient over 12 months compared to those without increased uptake (2.3 [0.0–4.0] versus -0.3 [-2.0–1.5] mmHg/year, p<0.001) and good correlations were observed between baseline 18F-fluoride TBRmean values and all echocardiographic measures of subsequent valve dysfunction (e.g. change in peak velocity, r=0.64; p<0.001). On multivariable analysis, baseline 18F-fluoride uptake was the only independent predictor of deterioration in bioprosthetic function, and all patients with TBRmean values ≥2.5 had evidence of overt bioprosthetic failure within 1 year of imaging.

Conclusion: 18F-Fluoride PET-CT detects early bioprosthetic valve degeneration before changes are apparent on echocardiography and acts as a powerful predictor of subsequent deterioration in valve performance. This technique holds major promise in assessing bioprosthetic valve durability, identifying early bioprosthetic valve degeneration and guiding patient management.

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