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Is cardiac computed tomography a reliable alternative to percutaneous coronary angiography for patients awaiting
Vivek Shrivastava1, Sriram Vundavalli, Leslie Mitchell
1Department of Interventional Radiology, Freeman Hospital, Newcastle, UK.
Insights
CT angiography is a reliable non-invasive tool for excluding coronary artery disease before valve surgery, especially in lower-risk patients. However, it has limitations with calcium deposits and arrhythmias, and a higher radiation dose than conventional angiography.
Area of Science:
- Cardiovascular Surgery
- Diagnostic Imaging
Background:
- Evaluating coronary artery disease (CAD) is crucial for patients undergoing non-coronary cardiac procedures.
- Percutaneous coronary angiography is the traditional method for CAD assessment.
Observation:
- A systematic review identified 11 high-quality studies comparing CT angiography (CTA) with conventional angiography for CAD exclusion.
- CTA utilizes 64-slice multi-detector technology for imaging coronary arteries.
Findings:
- CTA demonstrates a high negative predictive value (around 97%) for excluding significant coronary artery stenoses, making it a viable alternative to conventional angiography in select patients.
- CTA's accuracy is reduced in the presence of coronary calcifications and in small vessels (<1.5 mm).
- Scan limitations include inability to image patients with arrhythmias and a five-fold increase in radiation exposure compared to conventional angiography.
Implications:
- CTA can reliably exclude significant coronary artery disease, potentially replacing routine conventional angiography in lower atherosclerotic risk patients undergoing valve surgery.
- Careful patient selection is necessary due to CTA's limitations and increased radiation dose.
Abstract:
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether a CT angiogram could replace routine percutaneous coronary angiography for excluding coronary arterial disease for patients undergoing a non coronary cardiac procedure. Using the reported search 595 papers were identified. Eleven papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. We conclude that angiography with 64-slice multi-detector CT scanner provides reliable non-invasive imaging to exclude significant coronary artery stenoses prior to valve surgery. The negative predictive value of a normal CT scan is around 97%, thus providing a good alternative to conventional angiography in lower atherosclerotic risk patients. The ability of CT angiography to assess the reduction in luminal diameter is reduced in the presence of calcium deposits, and is also reduced in vessels under 1.5 mm. Further disadvantages include an inability to perform scans in patients with arrhythmias or atrial fibrillation, and a five times increased radiation dose compared to conventional angiography.
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