Coronary CTA and CT-FFR in trans-catheter aortic valve implantation candidates: a systematic review and meta-analysis
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Published on: June 3, 2018
Leonie M Becker1,2, Joyce Peper3, Dirk-Jan van Ginkel3
1Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands. l.becker@antoniusziekenhuis.nl.
Insights
Coronary computed tomography angiography (CCTA) effectively rules out obstructive coronary artery disease (CAD) in trans-catheter aortic valve implantation (TAVI) candidates, reducing unnecessary invasive procedures. CT-derived fractional flow reserve (CT-FFR) shows promise but requires further validation for routine use.
Area of Science:
- Cardiology
- Radiology
- Medical Imaging
Background:
- Trans-catheter aortic valve implantation (TAVI) requires pre-procedural screening for obstructive coronary artery disease (CAD).
- Invasive coronary angiography (ICA) is the current standard but often reveals no obstructive CAD, leading to unnecessary procedures.
- Coronary computed tomography angiography (CCTA) is a non-invasive imaging modality for CAD assessment.
Purpose of the Study:
- To systematically review and meta-analyze the diagnostic accuracy of CCTA and CT-derived fractional flow reserve (CT-FFR) for obstructive CAD in TAVI candidates.
- To evaluate the potential of CCTA and CT-FFR to reduce unnecessary ICA procedures in this population.
Main Methods:
- A systematic literature search was conducted across PubMed, Embase, and Web of Science for relevant studies.
- Studies involving CCTA and/or CT-FFR in TAVI candidates were included.
- A meta-analysis was performed to pool data on the primary endpoint: correct identification and rule-out of obstructive CAD.
Main Results:
- The meta-analysis included 34 articles, covering 7235 patients for CCTA and 1269 for CT-FFR.
- Pooled CCTA sensitivity was 94.0% and specificity 72.4% at the patient level.
- CT-FFR showed comparable overall diagnostic accuracy (sensitivity 93.2%, specificity 70.3%), but performed better than CCTA in direct comparative studies (sensitivity 83.9%, specificity 89.8% vs. 74.9%, 65.5%).
Conclusions:
- Negative CCTA accurately excludes obstructive CAD in TAVI candidates, potentially reducing pre-TAVI ICA.
- While CT-FFR demonstrated superior performance in head-to-head comparisons, its overall accuracy was similar to CCTA.
- Further research with larger studies and commercially available CT-FFR software is warranted before routine implementation in TAVI work-up.
Objectives:
Screening for obstructive coronary artery disease (CAD) with coronary computed tomography angiography (CCTA) could prevent unnecessary invasive coronary angiography (ICA) procedures during work-up for trans-catheter aortic valve implantation (TAVI). CT-derived fractional flow reserve (CT-FFR) improves CCTA accuracy in chest pain patients. However, its reliability in the TAVI population is unknown. This systematic review and meta-analysis assesses CCTA and CT-FFR in TAVI candidates.
Methods:
PubMed, Embase and Web of Science were searched for studies regarding CCTA and/or CT-FFR in TAVI candidates. Primary endpoint was correct identification and rule-out of obstructive CAD. Results were pooled in a meta-analysis.
Results:
Thirty-four articles were part of the meta-analysis, reporting results for CCTA and CT-FFR in 7235 and 1269 patients, respectively. Reference standard was mostly anatomical severity of CAD. At patient level, pooled CCTA sensitivity was 94.0% and specificity 72.4%. CT-FFR sensitivity was 93.2% and specificity 70.3% with substantial variation between studies. However, in studies that compared both, CT-FFR performed better than CCTA. Sensitivity of CCTA versus CT-FFR was 74.9% versus 83.9%, and specificity was 65.5% versus 89.8%.
Conclusions:
Negative CCTA accurately rules out CAD in the TAVI population. CCTA could lead to significant reduction in pre-TAVI ICA, but false positives remain high. Diagnostic accuracy of CT-FFR was comparable to that of CCTA in our meta-analyses, but in studies performing a direct comparison, CT-FFR performed better than CCTA. However, as most studies were small and used CT-FFR software exclusively available for research, a large study on CT-FFR in TAVI work-up using commercially available CT-FFR software would be appropriate before considering routine implementation.
Key Points:
Question Coronary artery disease (CAD) screening with invasive coronary angiography before trans-catheter aortic valve implantation (TAVI) is often retrospectively unnecessary, revealing no obstructive CAD. Findings Coronary CTA ruled out CAD in approximately half of TAVI candidates. CT-derived fractional flow reserve (CT-FFR) performed similarly overall but better than coronary CTA in direct comparison. Clinical relevance Addition of coronary CTA to TAVI planning-CT to screen for obstructive CAD could reduce negative invasive coronary angiographies in TAVI work-up. CT-FFR could reduce false-positive coronary CTA results, improving its gatekeeper function in this population, but more data is necessary.
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