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Published on: June 3, 2018
Computed Tomography Coronary Angiography as a Gatekeeper for Invasive Coronary Assessment Before Transcatheter Aortic
Anastasios Apostolos1, Nikolaos Ktenopoulos2, Theoni Theodoropoulou2
1Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London UB9 6JH, UK.
Insights
Computed tomography coronary angiography (CTCA) can reliably exclude significant coronary artery disease (CAD) in transcatheter aortic valve implantation (TAVI) candidates. This allows avoiding invasive coronary angiography (ICA) in many patients, optimizing care.
Area of Science:
- Cardiovascular Imaging and Intervention
- Interventional Cardiology
- Cardiac Surgery
Background:
- Transcatheter aortic valve implantation (TAVI) is the primary treatment for severe aortic stenosis.
- Coronary artery disease (CAD) frequently coexists in TAVI candidates, traditionally necessitating invasive coronary angiography (ICA).
- Routine pre-emptive coronary revascularization in stable TAVI candidates shows questionable benefit.
Purpose of the Study:
- To review the diagnostic performance of computed tomography coronary angiography (CTCA) for assessing coronary anatomy in TAVI candidates.
- To evaluate clinical outcomes and technical considerations of CTCA-guided strategies in the TAVI pathway.
- To propose an optimized paradigm for coronary assessment in the TAVI era.
Main Methods:
- Synthesized current evidence on CTCA diagnostic performance (sensitivity, negative predictive value) for significant proximal CAD.
- Reviewed clinical outcomes associated with CT-guided TAVI strategies.
- Analyzed technical considerations, limitations, and proposed a practical algorithm for CTCA integration.
Main Results:
- CTCA demonstrates high sensitivity (90-97%) and negative predictive value (94-99%) for excluding significant proximal CAD.
- CTCA can serve as a reliable gatekeeper, potentially avoiding unnecessary ICA in a substantial proportion of TAVI patients.
- Evidence suggests CTCA can be integrated into TAVI planning for simultaneous coronary assessment.
Conclusions:
- CTCA is a valuable tool for assessing coronary anatomy in TAVI candidates, potentially reducing the need for ICA.
- Integrating CTCA as a first-line screening tool can optimize resource utilization and maintain patient safety.
- A CTCA-guided strategy, reserving ICA for select cases, represents an evolving and efficient approach in TAVI.
Abstract:
Transcatheter aortic valve implantation (TAVI) has become the predominant treatment strategy for severe aortic stenosis across all surgical risk categories. The coexistence of coronary artery disease (CAD) in 40-75% of TAVI candidates has traditionally mandated pre-procedural invasive coronary angiography (ICA). However, computed tomography coronary angiography (CTCA), which is already integral to TAVI planning for annular sizing and access route evaluation, offers the potential to assess coronary anatomy simultaneously. Accumulating evidence demonstrates that CTCA possesses excellent sensitivity (90-97%) and high negative predictive value (94-99%) for excluding significant proximal CAD, potentially serving as a reliable gatekeeper to avoid unnecessary ICA in a substantial proportion of patients. This approach is particularly attractive given the questionable benefit of routine pre-emptive coronary revascularization in stable TAVI candidates, as demonstrated by the ACTIVATION and NOTION-3 trials. This review synthesizes the current evidence on the diagnostic performance of CTCA, clinical outcomes with CT-guided strategies, technical considerations and limitations, and the evolving paradigm of coronary assessment in the contemporary TAVI era. We propose a practical algorithm integrating CTCA as a first-line screening tool, reserving ICA for patients with suspected significant proximal disease, thereby optimizing resource utilization while maintaining patient safety.
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