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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
Tomography Versus Angiography for Coronary Stenoses Before Transcatheter Aortic Valve Implantation
Stefano Garzon1, José Mariani2, Guy Prado1
1Department of Cardiology, Einstein Hospital Israelita, São Paulo, Brazil; Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.
Insights
A computed tomography angiography (CTA)-first approach for coronary assessment before transcatheter aortic valve implantation (TAVI) shows similar long-term survival compared to invasive coronary angiography (ICA)-first. This CTA-first strategy effectively reduces invasive procedures for TAVI patients.
Area of Science:
- Cardiology
- Medical Imaging
- Interventional Cardiology
Background:
- Coronary artery disease (CAD) is prevalent in patients undergoing transcatheter aortic valve implantation (TAVI).
- Optimal pre-procedural coronary assessment strategy for TAVI remains unclear.
Purpose of the Study:
- To compare long-term outcomes of computed tomography angiography (CTA)-first versus invasive coronary angiography (ICA)-first strategies in TAVI patients.
- To evaluate the impact of pre-TAVI coronary assessment on all-cause mortality.
Main Methods:
- Retrospective comparison of 307 consecutive TAVI patients (ICA-first, n=150; CTA-first, n=157).
- Primary outcome: all-cause mortality.
- Median follow-up of 61.7 months.
Main Results:
- No significant difference in all-cause mortality between CTA-first and ICA-first strategies (unadjusted HR 0.88; adjusted HR 0.95).
- CTA-first strategy avoided invasive angiography in 73% of patients.
- A non-significant trend towards more late post-TAVI catheterization in the CTA-first group (HR 2.47).
- CAD identified a higher-risk phenotype, but pre-TAVI PCI did not lower mortality.
Conclusions:
- A CTA-first strategy provides equivalent long-term survival compared to ICA-first for TAVI patients.
- CTA-first approach spares most patients from invasive angiography.
- Recommends CTA-first as the default pre-TAVI coronary assessment strategy.
Abstract:
Coronary artery disease is common in patients undergoing transcatheter aortic valve implantation (TAVI), but the optimal preprocedural coronary assessment strategy is uncertain. We compared long-term outcomes of a computed tomography angiography (CTA)-first versus an invasive coronary angiography (ICA)-first strategy in 307 consecutive patients undergoing TAVI at a single center (ICA-first, n = 150; CTA-first, n = 157). The primary outcome was all-cause mortality. Over a median follow-up of 61.7 months, mortality did not differ between strategies (unadjusted hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.66-1.16), and assessment strategy was not an independent predictor of death after adjustment (HR 0.95, 95% CI 0.67-1.34). A CTA-first strategy avoided invasive angiography in 73% of patients, with a nonsignificant trend toward more late post-TAVI catheterization (HR 2.47, 95% CI 0.94-6.45). Pre-TAVI percutaneous coronary intervention was not associated with lower mortality, although coronary artery disease itself identified a higher-risk phenotype. In conclusion, a CTA-first strategy yielded equivalent long-term survival while sparing most patients invasive angiography, supporting its use as the default pre-TAVI coronary assessment strategy.
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