Diagnostic accuracy of computed tomography angiography for the exclusion of coronary artery disease in candidates for transcatheter aortic valve implantation

Strong, Christopher; Ferreira, António Miguel; Teles, Rui Campante; Mendes, G Sa; Abecasis, João; Cardoso, Gonçalo; Guerreiro, S; Freitas, P; Santos, Ana Coutinho; Saraiva, Carla; Brito, João; Raposo, Luís; Gonçalves, Pedro de Araújo; Gabriel, Henrique Mesquita; Almeida, Manuel; Mendes, Miguel

doi:10.1038/s41598-019-56519-3

Cited by 28 publications

(28 citation statements)

References 16 publications

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“…The diagnostic performance of cCTA in our study is comparable to or even higher than reported in the literature (Table 7) [13][14][15][16][17][18][19][20]23], even though a considerable proportion of our cohort did not undergo ICA after negative cCTA, leaving only the more severely diseased and more challenging patients for correlation. At the same time, our patients had comparable risk-factors, calcium burden, and ultimately a comparable prevalence of significant CAD (35.6%); with only Harris et al And Opolski et al reporting on a cohort with substantially higher prevalence (Table 7) [13,[15][16][17][18][19][20]23]. In contrast to other studies, no exclusion of patients with known CAD treated with stents [20,23], of technically challenging patients (e.g.…”

Section: Discussionsupporting

confidence: 83%

“…At the same time, our patients had comparable risk-factors, calcium burden, and ultimately a comparable prevalence of significant CAD (35.6%); with only Harris et al And Opolski et al reporting on a cohort with substantially higher prevalence (Table 7) [13,[15][16][17][18][19][20]23]. In contrast to other studies, no exclusion of patients with known CAD treated with stents [20,23], of technically challenging patients (e.g. based on high heart rate or arrhythmia) [13,19,24], or of patients with potentially preventable errors during acquisition (e.g.…”

Section: Discussionsupporting

confidence: 52%

“…One of the main challenges for cCTA in TAVI-patients is calcium burden, which enormously reduces accuracy and is responsible for the particularly high rate of false positive results [13,14,18,20,21,23,[33][34][35], and may also present challenges in extremely well contrasted examinations (Figure 3). Rossi et al reported that the diagnostic accuracy and probability to rule out CAD by cCTA decreases at CAC ≥ 400 and Anonni et al discuss using this cut-off for deciding whether or not to attempt the assessment of coronary arteries, whereas other studies discourage using such arbitrary thresholds [14,20,36,37].…”

Section: Discussionmentioning

confidence: 99%

“…If a stenosis was identified, it was graded with QCA (syngo.via VB40A, Siemens, Erlangen, Germany) using two orthogonal views [13][14][15]17,19,20]. A diameter-based stenosis of ≥ 50% was considered to be significant [13][14][15][16][17][18][19][20]23,30].…”

Section: Invasive Coronary Angiographymentioning

confidence: 99%

“…In addition, evidence has recently emerged that cCTA could also be used for the assessment of CAD in the high-risk group of TAVI-candidates [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Several studies have shown cCTA to be both safe and effective in patients screened for TAVI – especially for ruling out significant CAD given its high negative predictive value (NPV) [ 1 , 5 , 6 , 7 , 24 ].…”

Section: Introductionmentioning

confidence: 99%

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Combined Coronary CT-Angiography and TAVI-Planning: A Contrast-Neutral Routine Approach for Ruling-Out Significant Coronary Artery Disease

Gohmann

Lauten

Seitz

et al. 2020

JCM

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Background: Significant coronary artery disease (CAD) is a common finding in patients undergoing transcatheter aortic valve implantation (TAVI). Assessment of CAD prior to TAVI is recommended by current guidelines and is mainly performed via invasive coronary angiography (ICA). In this study we analyzed the ability of coronary CT-angiography (cCTA) to rule out significant CAD (stenosis ≥ 50%) during routine pre-TAVI evaluation in patients with high pre-test probability for CAD. Methods: In total, 460 consecutive patients undergoing pre-TAVI CT (mean age 79.6 ± 7.4 years) were included. All patients were examined with a retrospectively ECG-gated CT-scan of the heart, followed by a high-pitch-scan of the vascular access route utilizing a single intravenous bolus of 70 mL iodinated contrast medium. Images were evaluated for image quality, calcifications, and significant CAD; CT-examinations in which CAD could not be ruled out were defined as positive (CAD+). Routinely, patients received ICA (388/460; 84.3%; Group A), which was omitted if renal function was impaired and CAD was ruled out on cCTA (Group B). Following TAVI, clinical events were documented during the hospital stay. Results: cCTA was negative for CAD in 40.2% (188/460). Sensitivity, specificity, PPV, and NPV in Group A were 97.8%, 45.2%, 49.6%, and 97.4%, respectively. Median coronary artery calcium score (CAC) was higher in CAD+-patients but did not have predictive value for correct classification of patients with cCTA. There were no significant differences in clinical events between Group A and B. Conclusion: cCTA can be incorporated into pre-TAVI CT-evaluation with no need for additional contrast medium. cCTA may exclude significant CAD in a relatively high percentage of these high-risk patients. Thereby, cCTA may have the potential to reduce the need for ICA and total amount of contrast medium applied, possibly making pre-procedural evaluation for TAVI safer and faster.

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Section: Discussionsupporting

confidence: 83%

Section: Discussionsupporting

confidence: 52%

Section: Discussionmentioning

confidence: 99%

Section: Invasive Coronary Angiographymentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Combined Coronary CT-Angiography and TAVI-Planning: A Contrast-Neutral Routine Approach for Ruling-Out Significant Coronary Artery Disease

Gohmann

Lauten

Seitz

et al. 2020

JCM

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

et al. 2021

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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.

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Diagnostic accuracy of coronary computed tomography angiography for the evaluation of obstructive coronary artery disease in patients referred for transcatheter aortic valve implantation: a systematic review and meta-analysis

et al. 2022

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Objective To evaluate the diagnostic accuracy of coronary computed tomography angiography (CCTA) for the evaluation of obstructive coronary artery disease (CAD) in patients referred for transcatheter aortic valve implantation (TAVI). Methods EMBASE, PubMed/MEDLINE, and CENTRAL were searched for studies reporting accuracy of CCTA for the evaluation of obstructive CAD compared with invasive coronary angiography (ICA) as the reference standard. QUADAS-2 tool was used to assess the risk of bias. A bivariate random effects model was used to analyze, pool, and plot the diagnostic performance measurements across studies. Pooled sensitivity, specificity, positive ( + LR) and negative (−LR) likelihood ratio, diagnostic odds ratio (DOR), and hierarchical summary ROC curve (HSROC) were evaluated. Prospero registration number: CRD42021252527. Results Fourteen studies (2533 patients) were included. In the intention-to-diagnose patient-level analysis, sensitivity and specificity for CCTA were 97% (95% CI: 94–98%) and 68% (95% CI: 56–68%), respectively, and + LR and −LR were 3.0 (95% CI: 2.1–4.3) and 0.05 (95% CI: 0.03 – 0.09), with DOR equal to 60 (95% CI: 30–121). The area under the HSROC curve was 0.96 (95% CI: 0.94–0.98). No significant difference in sensitivity was found between single-heartbeat and other CT scanners (96% (95% CI: 90 – 99%) vs. 97% (95% CI: 94–98%) respectively; p = 0.37), whereas the specificity of single-heartbeat scanners was higher (82% (95% CI: 66–92%) vs. 60% (95% CI: 46 – 72%) respectively; p < 0.0001). Routine CCTA in the pre-TAVI workup could save 41% (95% CI: 34 – 47%) of ICAs if a disease prevalence of 40% is assumed. Conclusions CCTA proved an excellent diagnostic accuracy for assessing obstructive CAD in patients referred for TAVI; the use of single-heartbeat CT scanners can further improve these findings. Key Points • CCTA proved to have an excellent diagnostic accuracy for assessing obstructive CAD in patients referred for TAVI. • Routine CCTA in the pre-TAVI workup could save more than 40% of ICAs. • Single-heartbeat CT scanners had higher specificity than others in the assessment of obstructive CAD in patients referred for TAVI.

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Diagnostic accuracy of computed tomography angiography for the exclusion of coronary artery disease in candidates for transcatheter aortic valve implantation

Cited by 28 publications

References 16 publications

Combined Coronary CT-Angiography and TAVI-Planning: A Contrast-Neutral Routine Approach for Ruling-Out Significant Coronary Artery Disease

Combined Coronary CT-Angiography and TAVI-Planning: A Contrast-Neutral Routine Approach for Ruling-Out Significant Coronary Artery Disease

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

Diagnostic accuracy of coronary computed tomography angiography for the evaluation of obstructive coronary artery disease in patients referred for transcatheter aortic valve implantation: a systematic review and meta-analysis

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