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Published on: August 28, 2018
Coronary computed tomography angiography for heart team decision-making in multivessel coronary artery disease
Carlos Collet1,2, Yoshinobu Onuma3,4, Daniele Andreini5
1Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, AZ Amsterdam, the Netherlands.
Insights
Coronary computed tomography angiography (CTA) shows high agreement with conventional angiography for complex coronary artery disease treatment decisions. This non-invasive imaging may guide revascularization strategies, improving patient care.
Area of Science:
- Cardiovascular Imaging
- Interventional Cardiology
Background:
- Coronary computed tomography angiography (CTA) is a non-invasive method for diagnosing coronary artery disease.
- Its utility in complex coronary artery disease (CAD) requires further investigation.
Purpose of the Study:
- To assess agreement between heart teams on treatment decisions using coronary CTA versus conventional angiography.
- To evaluate the impact of fractional flow reserve derived from CTA (FFRCT) on treatment planning.
Main Methods:
- Heart teams (interventional cardiologist, cardiac surgeon, radiologist) evaluated patients with de novo left main or three-vessel CAD.
- Teams used either coronary CTA or conventional angiography, blinded to the other modality.
- Treatment recommendations (CABG, PCI, or equipoise) were based on SYNTAX Score II, predicting 4-year mortality.
Main Results:
- High agreement was observed between heart teams using coronary CTA and conventional angiography for treatment decisions (Cohen's kappa = 0.82).
- Teams agreed on revascularization segments in 80% of cases.
- FFRCT influenced treatment decisions in 7% of patients.
Conclusions:
- Coronary CTA-based treatment decisions demonstrate high concordance with conventional angiography in complex CAD.
- Coronary CTA holds potential as a sole imaging modality for treatment decision-making and planning in conjunction with clinical information.
Aims:
Coronary computed tomography angiography (CTA) has emerged as a non-invasive diagnostic method for patients with suspected coronary artery disease, but its usefulness in patients with complex coronary artery disease remains to be investigated. The present study sought to determine the agreement between separate heart teams on treatment decision-making based on either coronary CTA or conventional angiography.
Methods And Results:
Separate heart teams composed of an interventional cardiologist, a cardiac surgeon, and a radiologist were randomized to assess the coronary artery disease with either coronary CTA or conventional angiography in patients with de novo left main or three-vessel coronary artery disease. Each heart team, blinded for the other imaging modality, quantified the anatomical complexity using the SYNTAX score and integrated clinical information using the SYNTAX Score II to provide a treatment recommendations based on mortality prediction at 4 years: coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or equipoise between CABG and PCI. The primary endpoint was the agreement between heart teams on the revascularization strategy. The secondary endpoint was the impact of fractional flow reserve derived from coronary CTA (FFRCT) on treatment decision and procedural planning. Overall, 223 patients were included. A treatment recommendation of CABG was made in 28% of the cases with coronary CTA and in 26% with conventional angiography. The agreement concerning treatment decision between coronary CTA and conventional angiography was high (Cohen's kappa 0.82, 95% confidence interval 0.74-0.91). The heart teams agreed on the coronary segments to be revascularized in 80% of the cases. FFRCT was available for 869/1108 lesions (196/223 patients). Fractional flow reserve derived from coronary CTA changed the treatment decision in 7% of the patients.
Conclusion:
In patients with left main or three-vessel coronary artery disease, a heart team treatment decision-making based on coronary CTA showed high agreement with the decision derived from conventional coronary angiography suggesting the potential feasibility of a treatment decision-making and planning based solely on this non-invasive imaging modality and clinical information.
Trial Registration Number:
NCT02813473.
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