title: Imaging Pandora's Box: incidental findings in elderly patients evaluated for transcatheter aortic valve replacement.
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).
  
  
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
authors.forename: Nicholas M
authors.initials: NM
authors.lastname: Orme
authors.affiliation: Mayo Medical School, Mayo Clinic, Rochester, MN.
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Wright
authors.affiliation: Mayo Medical School, Mayo Clinic, Rochester, MN.
authors.forename: Gil E
authors.initials: GE
authors.lastname: Harmon
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
authors.forename: Vuyisile T
authors.initials: VT
authors.lastname: Nkomo
authors.affiliation: Department of Radiology, Mayo Clinic, Rochester, MN.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Williamson
authors.affiliation: Division of Cardiovascular Diseases, Minneapolis Heart Institute Foundation, Minneapolis, MN.
authors.forename: Paul
authors.initials: P
authors.lastname: Sorajja
authors.affiliation: Department of Radiology, Mayo Clinic, Rochester, MN.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Foley
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Kevin L
authors.initials: KL
authors.lastname: Greason
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Rakesh M
authors.initials: RM
authors.lastname: Suri
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
authors.forename: Charanjit S
authors.initials: CS
authors.lastname: Rihal
authors.affiliation: Department of Radiology, Mayo Clinic, Rochester, MN. Electronic address: young.phillip@mayo.edu.
authors.forename: Phillip M
authors.initials: PM
authors.lastname: Young
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography; D001021:Aortic Valve / Q000601:surgery; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging* / Q000601:surgery; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000379:methods; D006801:Humans; D033162:Incidental Findings; D008297:Male; D011300:Preoperative Care / Q000379:methods*; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed