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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
Combined Computed Coronary Tomography Angiography and Transcatheter Aortic Valve Implantation (TAVI) Planning
Dominik Felbel1, Christoph Buck1, Natalie Riedel2
1Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, Ulm University Heart Center, 89081 Ulm, Germany.
Insights
Combined computed coronary tomography angiography (cCTA) and TAVI planning CT can safely detect significant coronary artery disease in patients undergoing transcatheter aortic valve implantation (TAVI). This approach may replace invasive coronary angiography, especially in patients without prior stenting.
Area of Science:
- Cardiovascular Imaging
- Interventional Cardiology
- Radiology
Background:
- Coronary artery status evaluation is crucial before transcatheter aortic valve implantation (TAVI).
- The utility of combined computed coronary tomography angiography (cCTA) and TAVI planning CT for this assessment is not well-defined.
- This study investigates the role of cCTA and CT-derived fractional flow reserve (FFR) in detecting significant coronary artery disease (CAD) in severe aortic stenosis patients.
Purpose of the Study:
- To assess the safety and accuracy of combined cCTA and TAVI planning CT in detecting relevant proximal coronary artery disease.
- To determine if this combined imaging approach can replace invasive coronary angiography (ICA) prior to TAVI.
- To evaluate the diagnostic performance, including CT-derived FFR, in severe aortic stenosis patients.
Main Methods:
- Analysis of 101 consecutive TAVI patients who underwent both cCTA and TAVI planning CT using a 128-slice dual-source scanner.
- Comparison of cCTA detection of left main stem stenosis (>50%) or proximal coronary artery stenosis (>70%) against invasive coronary angiography (ICA).
- Inclusion of CT-derived fractional flow reserve (FFR) calculation.
Main Results:
- Out of 15 patients with significant coronary stenoses, cCTA correctly identified 14 (93.3%).
- False positive results were observed in 25 patients, with higher rates in those with prior percutaneous coronary intervention (PCI) (11/29).
- In patients without prior PCI, cCTA demonstrated improved classification performance (87.5%) with a high negative predictive value (98.5%).
Conclusions:
- Combined cCTA and CT-FFR with TAVI planning CT serves as an effective 'one-stop shop' for coronary assessment before TAVI.
- This integrated imaging approach can safely replace routine ICA for detecting relevant coronary artery stenosis in TAVI candidates.
- Diagnostic performance of cCTA is reduced in patients with coronary stents, necessitating careful interpretation in this subgroup.
Abstract:
Background: Before surgical or transcatheter aortic valve implantation (TAVI), coronary status evaluation is required. The role of combined computed coronary tomography angiography (cCTA) and TAVI planning CT in this context is not yet well elucidated. This study assessed whether relevant proximal coronary disease requiring coronary revascularization can be safely detected by combined cCTA and TAVI planning CT, including CT-derived fractional flow reserve (FFR) calculation in patients with severe aortic stenosis. Methods: This study analyzed patients with successful cCTA combined with TAVI planning CT using a 128-slice dual-source scanner. The detection via cCTA of relevant left main stem stenosis (>50%) or proximal coronary artery stenosis (>70%) was compared to invasive coronary angiography (ICA). Results: This study comprised 101 consecutive TAVI patients with a median age of 83 [77-86] years, a median STS score of 3.7 [2.4-6.1] and 54% of whom had known coronary artery disease. Of 15 patients with relevant coronary stenoses, 14 (93.3%) were detected with cCTA, while false positive results were found in 25 patients. Only in patients with previous percutaneous coronary stent implantation (PCI) were false positive rates (11/29) increased. In the subgroup without previous PCI, an improved classification performance of 87.5%, being mainly due to 11.1% false positive classifications, led to a negative predictive value of 98.5%. Conclusions: Combined cCTA and CT-FFR with TAVI planning CT via state-of-the-art scanners and protocols as a one-stop shop can replace routine ICA in patients prior to TAVI due to its safe detection of relevant coronary artery stenosis, although diagnostic performance of cCTA is only reduced in patients with coronary stents.
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