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Improved Registration of 3D CT Angiography with X-ray Fluoroscopy for Image Fusion During Transcatheter Aortic Valve Implantation
Published on: June 3, 2018
Dual-source CT imaging to plan transcatheter aortic valve replacement: accuracy for diagnosis of obstructive coronary
Brett S Harris1, Carlo N De Cecco, U Joseph Schoepf
1From the Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC 29425.
Insights
Computed tomographic (CT) scans for transcatheter aortic valve replacement (TAVR) planning accurately rule out obstructive coronary artery disease (CAD). This suggests that coronary catheter angiography may be unnecessary for TAVR candidates without obstructive CAD on CT.
Area of Science:
- Cardiovascular Imaging
- Interventional Cardiology
- Radiology
Background:
- Transcatheter aortic valve replacement (TAVR) is a common procedure for aortic stenosis.
- Accurate pre-procedural assessment of coronary artery disease (CAD) is crucial for TAVR planning.
- Computed tomographic (CT) imaging is increasingly used for TAVR planning.
Purpose of the Study:
- To evaluate the diagnostic accuracy of CT scans in identifying obstructive CAD in TAVR candidates.
- To compare the efficacy of CT imaging versus coronary catheter (CC) angiography for CAD detection and graft patency assessment.
Main Methods:
- Retrospective analysis of 100 TAVR candidates who underwent both TAVR planning CT and CC angiography.
- Assessment of native coronary artery stenosis (≥50%) and coronary bypass graft patency using both modalities.
- Calculation of sensitivity, specificity, positive predictive value, and negative predictive value (NPV) for CT compared to CC angiography.
Main Results:
- CT demonstrated high sensitivity (98.6% per patient) and NPV (93.8% per patient) for detecting obstructive CAD (≥50% stenosis).
- Per-patient sensitivity for detecting >70% stenosis was 100%.
- Agreement between CT and CC angiography for graft patency was high (114/115 grafts).
Conclusions:
- TAVR planning CT is highly sensitive and has a high NPV for excluding obstructive CAD.
- CT imaging can reliably assess coronary artery stenosis and graft patency in TAVR candidates.
- Pre-procedural coronary angiography may be avoidable in TAVR candidates with no obstructive CAD identified on CT.
Purpose:
To assess the accuracy of computed tomographic (CT) examinations performed for the purpose of transcatheter aortic valve replacement (TAVR) planning to diagnose obstructive coronary artery disease (CAD).
Materials And Methods:
With institutional review board approval, waivers of informed consent, and in compliance with HIPAA, 100 consecutive TAVR candidates (61 men, mean age 79.6 years ± 9.9) who underwent both TAVR planning CT (with a dual-source CT system) and coronary catheter (CC) angiographic imaging were retrospectively analyzed. At both modalities, the presence of stenosis in the native coronary arteries was assessed. Additionally, all coronary bypass grafts were rated as patent or occluded. With CC angiographic imaging as the reference standard, the accuracy of CT for lesion detection on a per-vessel and per-patient basis was calculated. The accuracy of CT for the assessment of graft patency was also analyzed.
Results:
For per-vessel and per-patient analysis for the detection of stenosis that was 50% or more in the native coronary arteries, CT imaging had, respectively, 94.4% and 98.6% sensitivity, 68.4% and 55.6% specificity, 94.7% and 93.8% negative predictive value (NPV), and 67.0% and 85.7% positive predictive value. Per-patient sensitivity of stenosis 50% or greater with CT for greater than 70% stenosis at CC angiographic imaging was 100%. All 12 vessels in which percutaneous coronary intervention was performed were correctly identified as demonstrating stenosis 50% or greater with CT. There was agreement between CT and CC angiographic imaging regarding graft patency in 114 of 115 grafts identified with CC angiographic imaging.
Conclusion:
TAVR planning CT has high sensitivity and NPV in excluding obstructive CAD. An additional preprocedural CC angiographic examination may not be required in TAVR candidates with a CT examination that does not show obstructive CAD.
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