Coronary computed tomography angiography for heart team decision-making in multivessel coronary artery disease

Collet, Carlos; Onuma, Yoshinobu; Andreini, Daniele; Sonck, Jeroen; Pompilio, Giulio; Mushtaq, Saima; Meir, Mark La; Miyazaki, Yosuke; Mey, Johan De; Gaemperli, Oliver; Ouda, Ahmed; Maureira, Juan Pablo; Mandry, Damien; Camenzind, Edoardo; Macron, Laurent; Doenst, Torsten; Teichgräber, Ulf; Sigusch, Holger H.; Asano, Taku; Katagiri, Yuki; Morel, Marie‐Angèle; Lindeboom, Wietze; Pontone, Gianluca; Lüscher, Thomas F.; Bartorelli, Antonio L.; Serruys, Patrick W.

doi:10.1093/eurheartj/ehy581

Cited by 131 publications

(134 citation statements)

References 25 publications

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“…The SYNTAX III Revolution trial showed that CT-FFR aids decision-making without need for ICA in patients with left main or 3-vessel CAD. A decision-making based on CTA and CT-FFR showed high agreement with the decision derived from ICA [126]. This study also showed that the addition of CT-FFR to CTA alone changed the treatment decision (between PCI and CABG) in 7% of the patients and modified selection of vessels for revascularization in 12% [127].…”

Section: Current Evidence Of Ct-ffrsupporting

confidence: 57%

Computed tomographic evaluation of myocardial ischemia

et al. 2020

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Myocardial ischemia is caused by a mismatch between myocardial oxygen consumption and oxygen delivery in coronary artery disease (CAD). Stratification and decision-making based on ischemia improves the prognosis in patients with CAD. Non-invasive tests used to evaluate myocardial ischemia include stress electrocardiography, echocardiography, single-photon emission computed tomography, and magnetic resonance imaging. Invasive fractional flow reserve is considered the reference standard for assessment of the hemodynamic significance of CAD. Computed tomography (CT) angiography has emerged as a first-line imaging modality for evaluation of CAD, particularly in the population at low to intermediate risk, because of its high negative predictive value; however, CT angiography does not provide information on the hemodynamic significance of stenosis, which lowers its specificity. Emerging techniques, e.g., CT perfusion and CT-fractional flow reserve, help to address this limitation of CT, by determining the hemodynamic significance of coronary artery stenosis. CT perfusion involves acquisition during the first pass of contrast medium through the myocardium following pharmacological stress. CTfractional flow reserve uses computational fluid dynamics to model coronary flow, pressure, and resistance. In this article, we review these two functional CT techniques in the evaluation of myocardial ischemia, including their principles, technology, advantages, limitations, pitfalls, and the current evidence.

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Section: Current Evidence Of Ct-ffrsupporting

confidence: 57%

Computed tomographic evaluation of myocardial ischemia

et al. 2020

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“…14,16 Furthermore, CTA-FFR CT has been shown to be equivalent to coronary angiography for planning coronary revascularisation. 34 In this study, the potential benefit of systematic pre-operative screening for CAD and selection of patients for revascularisation with a single non-invasive test in patients with lower extremity PAD was demonstrated. Through one year follow up, survival was improved vs. the current standard of care.…”

Section: Discussionmentioning

confidence: 86%

Pre-operative Diagnosis of Silent Coronary Ischaemia May Reduce Post-operative Death and Myocardial Infarction and Improve Survival of Patients Undergoing Lower Extremity Surgical Revascularisation

Krieviņš

Zellāns

Latkovskis

et al. 2020

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDS This study shows that pre-operative evaluation of patients undergoing lower extremity surgical revascularisation using coronary computed tomography derived fractional flow reserve can identify high risk patients with silent coronary ischaemia. This information can facilitate a multidisciplinary team approach to improve patient outcome. Increased focus on peri-operative cardiac care combined with selective post-operative coronary revascularisation of patients with silent ischaemia resulted in fewer cardiovascular deaths and myocardial infarctions, and improved one year survival compared with patients having standard pre-operative cardiac evaluation. If confirmed by future studies, this strategy may improve long term survival of patients with peripheral vascular disease. Objective: Patients undergoing peripheral vascular surgery have increased risk of death and myocardial infarction (MI), which may be due to unsuspected (silent) coronary ischaemia. The aim was to determine whether preoperative diagnosis of silent ischaemia using coronary computed tomography (CT) derived fractional flow reserve (FFR CT) can facilitate multidisciplinary care to reduce post-operative death and MI, and improve survival. Methods: This was a single centre prospective study with historic controls. Patients with no cardiac symptoms undergoing lower extremity surgical revascularisation with pre-operative coronary CTA-FFR CT testing were compared with historic controls with standard pre-operative testing. Silent coronary ischaemia was defined as FFR CT 0.80 distal to coronary stenosis with FFR CT 0.75 indicating severe ischaemia. End points included cardiovascular (CV) death, MI, and all cause death through one year follow up. Results: There were no statistically significant differences between CT angiography (CTA-FFR CT) (n ¼ 135) and control (n ¼ 135) patients with regard to age (66 AE 8 years), sex, comorbidities, or surgery performed. Coronary CTA showed ! 50% stenosis in 70% of patients with left main stenosis in 7%. FFR CT revealed silent coronary ischaemia in 68% of patients with severe ischaemia in 53%. The status of coronary ischaemia was unknown in the controls. At 30 days, CV death and MI in the CTA-FFR CT group were not statistically significantly different from controls (0% vs. 3.7% [p ¼ .060] and 0.7% vs. 5.2% [p ¼ .066], respectively). Post-operative coronary revascularisation was performed in 54 patients to relieve silent ischaemia (percutaneous coronary intervention in 47, coronary artery bypass graft in seven). At one year, CTA-FFR CT patients had fewer CV deaths (0.7% vs. 5.9%; p ¼ .036) and MIs (2.2% vs. 8.1%; p ¼ .028) and improved survival (p ¼ .018) compared with controls. Conclusion: Pre-operative diagnosis of silent coronary ischaemia in patients undergoing lower extremity revascularisation surgery can facilitate multidisciplinary patient care with selective post-operative coronary revascularisation. This strategy reduced post-operative death and MI and improved one year survival compared with st...

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“…CT angiography has become an important tool in the cardiac surgical armamentarium with an increase in the volume or transcatheter valve intervention and open and endovascular aortic surgery. CT imaging has become a valuable resource to help heart team decision making in the setting of coronary artery disease and transcatheter aortic valve replacement . The noninvasive nature of CT imaging and gated techniques have helped with precise radiologic diagnoses.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic dilemma in prosthetic valve endocarditis: Computed tomography to the rescue

et al. 2019

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A 58‐year‐old man with multiple myeloma, prior bioprosthetic valve, spinal hardware and multiple episodes of Corynebacterium amycolatum bacteremia was found to have a well‐seated valve without vegetations, paravalvular leak, abscess or degeneration over a period of 6 months on five separate transesophageal echocardiographic studies. Computed tomography angiography was performed which revealed vegetation at the level of the left ventricular outflow tract. Reoperative sternotomy and interrogation of the valve confirmed a 1.5‐cm vegetation with the same bacterium. The patient underwent a redo aortic valve replacement and recovered without any complications. He has been asymptomatic and culture negative on surveillance.

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Coronary computed tomography angiography for heart team decision-making in multivessel coronary artery disease

Cited by 131 publications

References 25 publications

Computed tomographic evaluation of myocardial ischemia

Computed tomographic evaluation of myocardial ischemia

Pre-operative Diagnosis of Silent Coronary Ischaemia May Reduce Post-operative Death and Myocardial Infarction and Improve Survival of Patients Undergoing Lower Extremity Surgical Revascularisation

Diagnostic dilemma in prosthetic valve endocarditis: Computed tomography to the rescue

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