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

Abstract

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.

Feasibility of Non-Invasive Coronary Artery Disease Screening with Coronary CT Angiography before Transcatheter Aortic Valve Implantation

“…Our study showed that CCTA had a high sensitivity of 89.6% and a negative predictive value of 97.7%, discriminating between patients with CAD-RADS ≤ 2 and patients with CAD-RADS ≥ 3. These results are in line with other studies on the diagnostic performance of CCTA for detecting CAD in the general population [ 5 , 6 , 7 , 15 ] and before TAVI [ 9 , 11 , 16 , 17 ]. Our population was composed of patients with a low mean surgical risk, as assessed by the EuroSCORE II and the STS score.…”

“…It is important to complete the available data on the subject because of the technical improvements that can improve the diagnostic performance of CCTA. In our study, we used a 256-row detector CT, while in the available meta-analyses, most studies used a 64- or 128-row detector CT [ 10 , 11 ].…”

“…Several studies have attempted to evaluate the ability of CCTA to detect significant CAD in the pre-TAVI work-up, with varying results [ 8 , 9 ]. Two recent meta-analyses showed that CCTA had excellent diagnostic accuracy for assessing obstructive CAD in patients referred for TAVI [ 10 , 11 ]. But there is still a need for recent supplementary data, especially at the vessel level.…”

Combined CT Coronary Artery Assessment and TAVI Planning

“…There are three meta-analyses available that focus on the performance of CTA in diagnosing CAD in the setting of the preprocedural TAVI period [ 46 , 47 , 48 ]. The publication by Chaikriangkrai et al [ 46 ] included 13 studies with a total of 1498 patients.…”

“…However, not all underwent TAVI: altogether, 26% of the patients were referred to surgical aortic valve replacement instead. The meta-analyses by van den Boogert et al [ 47 ] and Chaikriangkrai et al [ 46 ] were published in 2018, but the most recent one by Gatti et al [ 48 ] was published in 2022. The latter compiled data from 14 studies with a total of 2533 patients and applied a bivariate random-effects model to summarize the diagnostic performance of CTA for coronary artery assessment before TAVI.…”