DEtection of ProxImal Coronary stenosis in the work-up for Transcatheter aortic valve implantation using CTA (from the DEPICT CTA collaboration)

Abstract

Objectives Computed tomography angiography (CTA) is performed routinely in the work-up for transcatheter aortic valve implantation (TAVI), and could potentially replace invasive coronary angiography (ICA) to rule out left main (LM) and proximal coronary stenosis. The objectives were to assess the diagnostic yield and accuracy of pre-TAVI CTA to detect LM and proximal coronary stenosis of ≥ 50% and ≥ 70% diameter stenosis (DS). Methods The DEPICT CTA database consists of individual patient data from four studies with a retrospective design that analyzed the diagnostic accuracy of pre-TAVI CTA to detect coronary stenosis, as compared with ICA. Pooled data were used to assess diagnostic accuracy to detect coronary stenosis in the left main and the three proximal coronary segments on a per-patient and a per-segment level. We included 1060 patients (mean age: 81.5 years, 42.7% male). Results On ICA, the prevalence of proximal stenosis was 29.0% (≥ 50% DS) and 15.7% (≥ 70% DS). Pre-TAVI CTA ruled out ≥ 50% DS in 51.6% of patients with a sensitivity of 96.4%, specificity of 71.2%, PPV of 57.7%, and NPV of 98.0%. For ≥ 70% DS, pre-TAVI CTA ruled out stenosis in 70.0% of patients with a sensitivity of 96.7%, specificity of 87.5%, PPV of 66.9%, and NPV of 99.0%. Conclusion CTA provides high diagnostic accuracy to rule out LM and proximal coronary stenosis in patients undergoing work-up for TAVI. Clinical application of CTA as a gatekeeper for ICA would reduce the need for ICA in 52% or 70% of patients, using a threshold of ≥ 50% or ≥ 70% DS, respectively. Key Points • Clinical application of CTA as a gatekeeper for ICA would reduce the need for ICA in 52% or 70% of TAVI patients, using a threshold of ≥ 50% or ≥ 70% diameter stenosis. • The diagnostic accuracy of CTA to exclude proximal coronary stenosis in these patients is high, with a sensitivity of 96.4% and NPV of 98.0% for a threshold of ≥ 50%, and a sensitivity of 96.7% and NPV of 99.0% for a threshold of ≥ 70% diameter stenosis. • Atrial fibrillation and heart rate did not significantly affect sensitivity and NPV. However, a heart rate of < 70 b/min during CTA was associated with a significantly improved specificity and PPV.

Combined CT Coronary Artery Assessment and TAVI Planning

“…The utilization of CTA for coronary artery assessment in patients scheduled for TAVI has been investigated previously [ 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. An overview of available study experience in the context of combined coronary CTA and TAVI evaluation is provided in Table 1 .…”

“…At the same time, these CT system requirements are crucial for coronary artery image acquisition. The feasibility of coronary artery assessment with CTA in a subset of patients scheduled for TAVI has been established previously and based on further development in the field of CT technology, with improved spatial and temporal resolution, its potential value has been suggested [ 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Only recently, the addition of computational fluid dynamic-based and machine learning (ML)-based solutions for fractional flow reserve from CTA (CT–FFR) showed the potential to improve the diagnostic performance of CTA before TAVI [ 24 , 25 , 26 , 27 , 28 ].…”

Coronary Artery Disease in Patients with Aortic Stenosis and Transcatheter Aortic Valve Implantation: Implications for Management

“…[ 34 ] Van Boogert et al suggested CTA sensitivity, specificity, positive predictive value (PPV) and NPVs of 95, 65, 71 and 94% respectively, for detecting significant stenosis. [ 35 , 36 ] Likewise, a recent study including 127 patients compared CTA with ICA images, and an excellent NPV for significant CAD as determined by stenosis ≥50% (97.5%) and for severe CAD with stenosis ≥70% (96.3%) were detected, suggesting a good CTA performance for ruling out CAD pre-TAVI procedure. [ 35 ] Van den Boogert et al used the DEPICT CTA database to demonstrate higher CTA diagnostic accuracy to rule out left main (LM) and proximal coronary stenosis in patients undergoing work-up for TAVI, with a sensitivity of 96.4% and NPV of 98.0% for a threshold of ≥50%, and a sensitivity of 96.7% and NPV of 99.0% for a threshold of ≥70% diameter stenosis.…”

“…[ 35 ] Van den Boogert et al used the DEPICT CTA database to demonstrate higher CTA diagnostic accuracy to rule out left main (LM) and proximal coronary stenosis in patients undergoing work-up for TAVI, with a sensitivity of 96.4% and NPV of 98.0% for a threshold of ≥50%, and a sensitivity of 96.7% and NPV of 99.0% for a threshold of ≥70% diameter stenosis. [ 36 ] Therefore, CTA may become an important tool in the stratification of CAD among TAVI candidates, particularly with the increasing number of lower-risk patients. [ 17 ]…”

Correlation of Computed Tomographic Angiography in Patients Undergoing Coronary Artery Bypass Grafting and Effect of Standardized Rehabilitation Nursing

“…The iterative reconstruction algorithm is an image reconstruction technique, which can obtain diagnostic images under low scanning conditions. Although the iterative algorithm has a large amount of computation and takes a long time, it is still considered to be a better reconstruction method for incomplete projection and projection data with noise [ 15 ]. The iterative algorithm divides the whole process of the image into many times and improves the image processing step by step.…”