Sex-specific utility of pulmonary artery metrics in predicting pulmonary hypertension and survival after TAVI: insights from advanced CT imaging

OBJECTIVE: Pulmonary hypertension (PH) significantly affects outcomes after transcatheter aortic valve implantation (TAVI), with sex-specific differences indicating the need for tailored strategies. This study investigated the predictive value of CT-derived main pulmonary artery (MPA) dimensions and ratios, focusing on diagnostic accuracy and prognostic relevance in male and female TAVI patients. MATERIALS AND METHODS: A retrospective analysis of 526 patients (263 male, 263 female) undergoing TAVI was performed. PH was defined echocardiographically according to European Society of Cardiology (ESC) guidelines. Pre-procedural CT measurements of MPA, ascending aorta (AA), and derived ratios (e.g., MPA/AA) were analyzed. Sex-specific cut-offs were determined using area under the receiver operating characteristic (AUROC) analyses and validated with survival curves and Cox regression. RESULTS: MPA and its ratios outperformed right and left pulmonary artery metrics in detecting PH. Overall cut-offs were MPA ≥ 29.5 mm and MPA/AA ≥ 0.76. In men, elevated MPA or MPA/AA showed strong associations with PH, whereas in women, higher cut-offs (MPA ≥ 30.0 mm; MPA/AA ≥ 0.86) were less diagnostically useful. Importantly, the MPA/AA ratio predicted long-term survival only in men (hazard ratio (HR) = 1.857, p = 0.006), underlining its limited prognostic role in females. CONCLUSION: CT-derived pulmonary artery metrics are valuable for predicting PH and survival in male TAVI patients. Incorporating the MPA/AA ratio into clinical practice may improve risk stratification in men, while limited diagnostic utility in women highlights the need for alternative markers. Sex-specific approaches should be pursued to optimize outcomes across all PH etiologies. CRITICAL RELEVANCE STATEMENT: CT-derived pulmonary artery metrics reliably predict PH and long-term survival after TAVI, particularly in men, emphasizing their diagnostic and prognostic value while underscoring the need for sex-specific thresholds and alternative markers in women. KEY POINTS: PH impacts TAVI outcomes, yet sex-specific radiological predictors remain insufficiently investigated. The pulmonary artery to AA ratio predicted survival in men but showed no prognostic value for women. Implementing sex-specific imaging assessments improves risk stratification in men, highlighting the need for distinct diagnostic strategies for women.