1Universitätsklinikum Jena Klinik für Innere Medizin I - Kardiologie Jena, Deutschland; 2Institut für diagnostische und interventionelle Radiologie Jena, Deutschland
Background:
Coronary artery disease (CAD) is a common finding in patients referred for transcatheter aortic valve replacement (TAVR). Treatment strategies differ between centers due to controversial data regarding both, physiological evaluation and prognostic and symptomatic significance of CAD in this high risk group. In addition to computed tomography (CT) for the assessment of access strategies, prosthesis sizing and prediction of appropriate projection angles for prosthesis deployment (TAVR CT), nearly all patients receive an invasive coronary angiography (ICA) prior to TAVR for coronary assessment as standard of care. Several studies analyzed concomitant coronary computed tomography angiography (CCTA) as an alternative to ICA in patients undergoing TAVR showing inconclusive results, mostly due to high coronary calcium.
Methods:
In this retrospective study we analyzed the feasibility of coronary artery evaluation using data acquisition from TAVR CT. All subjects were examined on a 256-detector row CT scanner (Revolution CT, GE Healthcare, Waukesha, Wisconsin, US) with a 16 cm wide-area gemstone detector enabling whole-heart imaging in a single-beat without moving the scanner table. Patients with a history of coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with a coronary stent diameter <3,5mm were excluded. We analyzed 5 coronary segments: left main (LM), proximal and medial left anterior descending (LAD), proximal circumflex artery (Cx) and proximal right coronary artery (RCA). ICA was examined by two independent interventional cardiologists; CT scans were analyzed by a blinded interventional cardiologist and a radiologist. Significant CAD was defined as at least 50% stenosis on Quantitative Coronary Analysis (QCA) for ICA and on visual evaluation on CT.
Results:
The study included 56 consecutive patients (mean age 80.5±7 years, 57.1% female, atrial fibrillation 30.3%, mean HF 76±16/min, previous PCI in 16.1%) referred for TAVR in our center in 2018. All patients underwent both, TAVR CT and ICA as standard-of-care prior to TAVR. 52 patients (93%) showed signs of CAD in CT, in 25 patients (44%) we could safely exclude relevant CAD. 27 patients were graded as intermediate or high grade stenosis on CT which could be confirmed in 18 (32%) patients on ICA. 5 patients (9%) were treated with PCI prior to TAVR.
Conclusion:
Assesment of coronary artery disease using TAVR CT data and avoiding further invasive evaluation can be safely used in selected patients undergoing percutaneous aortic valve replacement resulting in less radiation and contrast agent exposure as well as potentially lower complication rates on access site. Further studies on larger patient cohorts are needed to make the most of TAVR CT and clarify prognostic implications of this approach.