Early Prediction of Post-TAVR Left Ventricular Remodeling Using CT-Derived Radiomics and Clinical Variables

Background: Adverse left ventricular (LV) remodeling after transcatheter aortic valve replacement (TAVR) is associated with impaired functional recovery and adverse long-term outcomes, yet imaging-based risk stratification remains limited. Objectives: This study sought to determine whether CT-derived radiomic and geometric myocardial features, integrated with procedural and clinical variables, can predict adverse LV remodeling after TAVR. Methods: We retrospectively analyzed 232 consecutive TAVR recipients with paired pre- and post-procedural LV mass index (LVMI) measurements. Adverse remodeling was defined as a [≥]10% increase in LVMI at follow-up. Pre-procedural CT was used to derive three-dimensional LV geometric descriptors, ray-tracing wall-thickness metrics, and myocardial texture radiomic features. Random forest classifiers were developed across six models of sequentially increasing complexity. Results: Adverse LV remodeling occurred in 52 patients (22.4%). Geometry-only model showed limited discrimination (AUC 0.62), whereas wall-thickness radiomics substantially improved performance (AUC 0.84). A multimodal pre-procedural model combining CT radiomics with pre-procedural LVMI, residual valve insufficiency, and prior coronary revascularization achieved an AUC of 0.86 (95% CI 0.73 to 0.98). Addition of post-procedural mean transvalvular gradient further improved discrimination (AUC 0.91, 95% CI 0.81 to 0.98). SHAP analysis identified post-procedural mean aortic gradient and radiomic markers of myocardial heterogeneity as the leading predictors. Conclusions: CT-derived radiomic characterization of myocardial heterogeneity provides incremental prognostic information beyond conventional geometric assessment for identifying patients at risk of adverse LV remodeling after TAVR. These findings extend the role of pre-procedural CT beyond anatomical planning toward quantitative myocardial phenotyping and individualized risk stratification, although prospective validation is required to establish clinical utility.