CT coronary artery assessment in patients undergoing transcatheter aortic valve implantation

Jakob Voran (Kiel)1, K. Mostafa (Kiel)2, C. Wolf (Kiel)2, M. Müller (Kiel)1, A. Pohlmeyer (Kiel)1, J. Frank (Kiel)1, M. Salem (Kiel)1, G. Lutter (Kiel)3, M. Saad (Kiel)1, P. Langguth (Kiel)2, H. Seoudy (Kiel)1, D. Frank (Kiel)1

1Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie, Angiologie und internistische Intensivmedizin Kiel, Deutschland; 2Klinik für Radiologie und Neuroradiologie, UKSH, Campus Kiel Kiel, Deutschland; 3Universitätsklinikum Schleswig-Holstein Klinik für Herz- und Gefäßchirurgie Kiel, Deutschland


Background: Computed tomography (CT) angiography is a fundamental imaging technique in the context of transcatheter aortic valve implantation (TAVI). In addition, CT is also recommended as a first-line imaging test for patients with suspected coronary artery disease. As TAVI expands to lower risk patients, CT may gain increasing importance in identifying patients without significant concomitant coronary artery disease who may skip routine invasive coronary angiography before TAVI. The objective of this study was to evaluate the diagnostic performance of CT coronary artery assessment using the pre-TAVI CT scan.

A total of 257 patients undergoing transfemoral TAVI between January 2018 and May 2022 were included in the analysis. Patients with known coronary artery disease, insufficient visualization of the coronary arteries or cardiac implantable electronic devices were excluded. All patients received a standard TAVI CT scan and routinely underwent invasive coronary angiography prior to the TAVI procedure. Using pre-TAVI CT scans, total coronary artery calcium score was calculated  by two radiologists blinded to the results of the invasive coronary angiography. 

Significant coronary artery disease requiring percutaneous coronary intervention was present in 61 patients (23.7%). Median total coronary artery calcium score was 422 AU (IQR 140-1141 AU). Coronary artery calcium score had acceptable diagnostic performance in identifying patients with significant coronary artery disease (AUC 0.76, 95% CI 0.69-0.83, p<0.001; sensitivity 82.1%, and specificity 60.7% at a cutoff level of 981 AU). A coronary artery calcium score of <32 AU had a 100% specificity and correctly identified 36 patients without relevant coronary artery disease. A sensitivity of 96%, as suggested in the 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes, was achieved using a coronary calcium score of >2881 AU; however, specificity (14.8%) was poor.

Low total coronary artery calcium scores using standard pre-TAVI CT scans identified patients without significant coronary artery disease and may potentially streamline the preprocedural workup in selected patients scheduled for TAVI. 
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