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Langenbach MC, Langenbach IL, Foldyna B, Mauri V, Klein K, Macherey-Meyer S, Heyne S, Meertens M, Lee S, Baldus S, Maintz D, Halbach M, Adam M, Wienemann H. Advanced CT measures of coronary artery disease with intermediate stenosis in patients with severe aortic valve stenosis. Eur Radiol 2024; 34:4897-4908. [PMID: 38189982 PMCID: PMC11255039 DOI: 10.1007/s00330-023-10549-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/20/2023] [Accepted: 12/04/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Coronary artery disease (CAD) and severe aortic valve stenosis (AS) frequently coexist. While pre-transcatheter aortic valve replacement (TAVR) computed tomography angiography (CTA) allows to rule out obstructive CAD, interpreting hemodynamic significance of intermediate stenoses is challenging. This study investigates the incremental value of CT-derived fractional flow reserve (CT-FFR), quantitative coronary plaque characteristics (e.g., stenosis degree, plaque volume, and composition), and peri-coronary adipose tissue (PCAT) density to detect hemodynamically significant lesions among those with AS and CAD. MATERIALS AND METHODS We included patients with severe AS and intermediate coronary lesions (20-80% diameter stenosis) who underwent pre-TAVR CTA and invasive coronary angiogram (ICA) with resting full-cycle ratio (RFR) assessment between 08/16 and 04/22. CTA image analysis included assessment of CT-FFR, quantitative coronary plaque analysis, and PCAT density. Coronary lesions with RFR ≤ 0.89 indicated hemodynamic significance as reference standard. RESULTS Overall, 87 patients (age 77.9 ± 7.4 years, 38% female) with 95 intermediate coronary artery lesions were included. CT-FFR showed good discriminatory capacity (area under receiver operator curve (AUC) = 0.89, 95% confidence interval (CI) 0.81-0.96, p < 0.001) to identify hemodynamically significant lesions, superior to anatomical assessment, plaque morphology, and PCAT density. Plaque composition and PCAT density did not differ between lesions with and without hemodynamic significance. Univariable and multivariable analyses revealed CT-FFR as the only predictor for functionally significant lesions (odds ratio 1.28 (95% CI 1.17-1.43), p < 0.001). Overall, CT-FFR ≤ 0.80 showed diagnostic accuracy, sensitivity, and specificity of 88.4% (95%CI 80.2-94.1), 78.5% (95%CI 63.2-89.7), and 96.2% (95%CI 87.0-99.5), respectively. CONCLUSION CT-FFR was superior to CT anatomical, plaque morphology, and PCAT assessment to detect functionally significant stenoses in patients with severe AS. CLINICAL RELEVANCE STATEMENT CT-derived fractional flow reserve in patients with severe aortic valve stenosis may be a useful tool for non-invasive hemodynamic assessment of intermediate coronary lesions, while CT anatomical, plaque morphology, and peri-coronary adipose tissue assessment have no incremental or additional benefit. These findings might help to reduce pre-transcatheter aortic valve replacement invasive coronary angiogram. KEY POINTS • Interpreting the hemodynamic significance of intermediate coronary stenoses is challenging in pre-transcatheter aortic valve replacement CT. • CT-derived fractional flow reserve (CT-FFR) has a good discriminatory capacity in the identification of hemodynamically significant coronary lesions. • CT-derived anatomical, plaque morphology, and peri-coronary adipose tissue assessment did not improve the diagnostic capability of CT-FFR in the hemodynamic assessment of intermediate coronary stenoses.
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Affiliation(s)
- Marcel C Langenbach
- Faculty of Medicine and University Hospital Cologne, Institute for Diagnostic and Interventional Radiology, University of Cologne, Kerpener Strasse 62, Cologne, 50937, Germany.
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA.
| | - Isabel L Langenbach
- Faculty of Medicine and University Hospital Cologne, Institute for Diagnostic and Interventional Radiology, University of Cologne, Kerpener Strasse 62, Cologne, 50937, Germany
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Borek Foldyna
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Victor Mauri
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Konstantin Klein
- Faculty of Medicine and University Hospital Cologne, Institute for Diagnostic and Interventional Radiology, University of Cologne, Kerpener Strasse 62, Cologne, 50937, Germany
| | - Sascha Macherey-Meyer
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Sebastian Heyne
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Max Meertens
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Samuel Lee
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Stephan Baldus
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - David Maintz
- Faculty of Medicine and University Hospital Cologne, Institute for Diagnostic and Interventional Radiology, University of Cologne, Kerpener Strasse 62, Cologne, 50937, Germany
| | - Marcel Halbach
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Matti Adam
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Hendrik Wienemann
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
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Brendel JM, Walterspiel J, Hagen F, Kübler J, Paul JF, Nikolaou K, Gawaz M, Greulich S, Krumm P, Winkelmann M. Coronary artery disease evaluation during transcatheter aortic valve replacement work-up using photon-counting CT and artificial intelligence. Diagn Interv Imaging 2024; 105:273-280. [PMID: 38368176 DOI: 10.1016/j.diii.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/19/2024]
Abstract
PURPOSE The purpose of this study was to evaluate the capabilities of photon-counting (PC) CT combined with artificial intelligence-derived coronary computed tomography angiography (PC-CCTA) stenosis quantification and fractional flow reserve prediction (FFRai) for the assessment of coronary artery disease (CAD) in transcatheter aortic valve replacement (TAVR) work-up. MATERIALS AND METHODS Consecutive patients with severe symptomatic aortic valve stenosis referred for pre-TAVR work-up between October 2021 and June 2023 were included in this retrospective tertiary single-center study. All patients underwent both PC-CCTA and ICA within three months for reference standard diagnosis. PC-CCTA stenosis quantification (at 50% level) and FFRai (at 0.8 level) were predicted using two deep learning models (CorEx, Spimed-AI). Diagnostic performance for global CAD evaluation (at least one significant stenosis ≥ 50% or FFRai ≤ 0.8) was assessed. RESULTS A total of 260 patients (138 men, 122 women) with a mean age of 78.7 ± 8.1 (standard deviation) years (age range: 51-93 years) were evaluated. Significant CAD on ICA was present in 126/260 patients (48.5%). Per-patient sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 96.0% (95% confidence interval [CI]: 91.0-98.7), 68.7% (95% CI: 60.1-76.4), 74.3 % (95% CI: 69.1-78.8), 94.8% (95% CI: 88.5-97.8), and 81.9% (95% CI: 76.7-86.4) for PC-CCTA, and 96.8% (95% CI: 92.1-99.1), 87.3% (95% CI: 80.5-92.4), 87.8% (95% CI: 82.2-91.8), 96.7% (95% CI: 91.7-98.7), and 91.9% (95% CI: 87.9-94.9) for FFRai. Area under the curve of FFRai was 0.92 (95% CI: 0.88-0.95) compared to 0.82 for PC-CCTA (95% CI: 0.77-0.87) (P < 0.001). FFRai-guidance could have prevented the need for ICA in 121 out of 260 patients (46.5%) vs. 97 out of 260 (37.3%) using PC-CCTA alone (P < 0.001). CONCLUSION Deep learning-based photon-counting FFRai evaluation improves the accuracy of PC-CCTA ≥ 50% stenosis detection, reduces the need for ICA, and may be incorporated into the clinical TAVR work-up for the assessment of CAD.
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Affiliation(s)
- Jan M Brendel
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany
| | - Jonathan Walterspiel
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany
| | - Florian Hagen
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany
| | - Jens Kübler
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany
| | - Jean-François Paul
- Institut Mutualiste Montsouris, Department of Radiology, Cardiac Imaging, 75014 Paris, France; Spimed-AI, 75014 Paris, France
| | - Konstantin Nikolaou
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany
| | - Meinrad Gawaz
- Department of Internal Medicine III, Cardiology and Angiology, University of Tübingen, 72076 Germany
| | - Simon Greulich
- Department of Internal Medicine III, Cardiology and Angiology, University of Tübingen, 72076 Germany
| | - Patrick Krumm
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany.
| | - Moritz Winkelmann
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany
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Mascherbauer J, Rudolph T, Strauch JT, Seiffert M, Bleiziffer S, Bartko PE, Zielinski M, Vijayan A, Bramlage P, Hengstenberg C. Preprocedural assessment of coronary artery disease in patients undergoing transcatheter aortic valve implantation: Rationale and design of the EASE-IT CT registry. Eur J Clin Invest 2024:e14274. [PMID: 38925546 DOI: 10.1111/eci.14274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/06/2024] [Accepted: 06/16/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Invasive coronary angiography (ICA) is the standard for pre-procedural assessment of coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI). However, it requires hospitalization and can be associated with complications. Computed tomography angiography (CTA) may be a viable alternative to rule out prognostically relevant CAD. METHODS The EASE-IT CT Registry is an investigator-initiated, prospective, observational, multicentre pilot registry involving patients aged ≥75 years with severe aortic stenosis (AS) intended to implant a transcatheter heart valve (THV) of the SAPIEN family. A total of 150 patients will be recruited from four sites in Germany and Austria. The registry will consist of two prospective cohorts: the investigational CTA-only cohort and the CTA + ICA control cohort. The CTA-only cohort will enrol 100 patients in whom significant (≥50%) left main (LM) and/or proximal left anterior descending artery (LAD) stenosis are ruled out on CTA. The CTA + ICA control cohort will enrol 50 patients who have undergone both CTA and ICA before TAVI and in whom ≥50% LM/proximal LAD stenosis has been ruled out by CTA. Three composite endpoints will be assessed at 3 months post-TAVI: CAD-specific endpoints, VARC-3-defined device success and early safety. CONCLUSION The EASE-IT CT Registry evaluates whether TAVI can be carried out safely without performing ICA if prognostically relevant CAD of the LM/proximal LAD is ruled out with CTA. If so, the omission of ICA would help streamline the pre-procedural workup of TAVI patients.
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Affiliation(s)
- Julia Mascherbauer
- Department of Internal Medicine 3, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Tanja Rudolph
- Heart and Diabetes Center North Rhine-Westphalia, Bad Oeynhausen, Germany
| | - Justus T Strauch
- Department of Cardiology and Angiology, BG University Hospital Bergmannsheil Bochum, Ruhr university, Bochum, Germany
| | - Moritz Seiffert
- Department of Cardiology and Angiology, BG University Hospital Bergmannsheil Bochum, Ruhr university, Bochum, Germany
| | - Sabine Bleiziffer
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, North Rhine-Westphalia, University Hospital, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Philipp Emanuel Bartko
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Marie Zielinski
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Anjaly Vijayan
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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Diller GP, Gerwing M, Boroni Grazioli S, De-Torres-Alba F, Radke RM, Vormbrock J, Baumgartner H, Kaleschke G, Orwat S. Utility of Coronary Computed Tomography Angiography in Patients Undergoing Transcatheter Aortic Valve Implantation: A Meta-Analysis and Meta-Regression Based on Published Data from 7458 Patients. J Clin Med 2024; 13:631. [PMID: 38276138 PMCID: PMC10816478 DOI: 10.3390/jcm13020631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/12/2024] [Accepted: 01/19/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Coronary CT angiography (CCTA) may detect coronary artery disease (CAD) in transcatheter aortic valve implantation (TAVI) patients and may obviate invasive coronary angiography (ICA) in selected patients. We assessed the diagnostic accuracy of CCTA for detecting CAD in TAVI patients based on published data. METHODS Meta-analysis and meta-regression were performed based on a comprehensive electronic search, including relevant studies assessing the diagnostic accuracy of CCTA in the setting of TAVI patients compared to ICA. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated on a patient and per segment level. RESULTS Overall, 27 studies (total of 7458 patients) were included. On the patient level, the CCTA's pooled sensitivity and NPV were 95% (95% CI: 93-97%) and 97% (95% CI: 95-98%), respectively, while the specificity and PPV were at 73% (95% CI: 62-82%) and 64% (95% CI: 57-71%), respectively. On the segmental coronary vessel level, the sensitivity and NPV were 90% (95% CI: 79-96%) and 98% (95% CI: 97-99%). CONCLUSIONS This meta-analysis highlights CCTA's potential as a first-line diagnostic tool although its limited PPV and specificity may pose challenges when interpreting heavily calcified arteries. This study underscores the need for further research and protocol standardization in this area.
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Affiliation(s)
- Gerhard-Paul Diller
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany (G.K.); (S.O.)
| | - Mirjam Gerwing
- Clinic of Radiology, University Hospital Muenster, 48149 Muenster, Germany
| | - Simona Boroni Grazioli
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany (G.K.); (S.O.)
| | - Fernando De-Torres-Alba
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany (G.K.); (S.O.)
| | - Robert M. Radke
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany (G.K.); (S.O.)
| | - Julia Vormbrock
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany (G.K.); (S.O.)
| | - Helmut Baumgartner
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany (G.K.); (S.O.)
| | - Gerrit Kaleschke
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany (G.K.); (S.O.)
| | - Stefan Orwat
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany (G.K.); (S.O.)
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Rajiah PS, Alkadhi H, Van Mieghem NM, Budde RPJ. Utility of Photon Counting CT in Transcatheter Structural Heart Disease Interventions. Semin Roentgenol 2024; 59:32-43. [PMID: 38388095 DOI: 10.1053/j.ro.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 02/24/2024]
Affiliation(s)
| | - Hatem Alkadhi
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicolas M Van Mieghem
- Department of Cardiology, Cardiovascular Institute, Thorax Center, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ricardo P J Budde
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Qiao J, Li S, Yang H, Chen X, Zhu T, Li Q, Wan W, Xu Y, Ge B, Zhao Y, Tang Y, Li F, He Y, Xia L. Subtraction Improves the Accuracy of Coronary CT Angiography in Patients with Severe Calcifications in Identifying Moderate and Severe Stenosis: A Multicenter Study. Acad Radiol 2023; 30:2801-2810. [PMID: 36586762 DOI: 10.1016/j.acra.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/06/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022]
Abstract
RATIONALE AND OBJECTIVES To investigate the diagnostic accuracy of subtraction coronary computed tomographic angiography (CCTAsub) in identifying ≥ 50% and ≥ 70% coronary stenosis in patients with different degrees of calcification. MATERIALS AND METHODS In this study, 180 patients with coronary calcified plaques who underwent both coronary CT angiography and invasive coronary angiography (ICA) were prospectively enrolled at five centers. Patients were divided into three groups according to the Agatston score: group A (low to moderate, < 400), group B (high, 400-999), and group C (very high, ≥ 1000). Diagnostic accuracies estimated by area under the receiver operating characteristic curve (AUC) were compared between conventional CCTA (CCTAcon) and CCTAsub, with ICA as a reference standard. RESULTS There were 86 patients in group A, 44 in group B, and 50 in group C. In identifying ≥ 70% coronary stenosis, subtraction improved the diagnostic accuracies on a per-segment basis in group B (AUC: 0.80 vs 0.92, p = 0.001) and group C (AUC: 0.75 vs 0.84, p = 0.001) after subtraction. When identifying ≥ 50% coronary stenosis, the per-segment AUC of CCTAsub in group B and C were significantly higher than that in CCTAcon (group B: 0.81 vs 0.92, p < 0.001; group C: 0.77 vs 0.88, p < 0.001). However, no improvement was observed in group A. CONCLUSION Subtraction achieved better diagnostic accuracy in patients with Agatston score ≥ 400, both in identifying ≥ 50% and ≥ 70% coronary stenosis, which was instructive for the application of subtraction in clinical practice.
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Affiliation(s)
- Jinhan Qiao
- From the Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Li
- Department of Radiology, People's Hospital, Hubei University of Medicine, Shiyan, China
| | - Hongzhi Yang
- Department of Radiology, Xidian Group Hospital, Xi'an, China
| | - Xiaolong Chen
- Image Center Shaanxi Provincial People's Hospital, Xi'an, China
| | - Tingting Zhu
- From the Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qian Li
- From the Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weijia Wan
- From the Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yinghao Xu
- Canon Medical Systems (China) CO.,LTD., Building 205, Yard NO.A10, JiuXianQiao North Road, ChaoYang District, 100015, Beijing
| | - Bing Ge
- Canon Medical Systems (China) CO.,LTD., Building 205, Yard NO.A10, JiuXianQiao North Road, ChaoYang District, 100015, Beijing
| | - Yun Zhao
- From the Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuanyuan Tang
- From the Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fang Li
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Bejing, China; Department of Radiology, Beijing Chest Hospital, Capital Medical University, Beijing, China.
| | - Yi He
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Bejing, China.
| | - Liming Xia
- From the Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Belur AD, Solankhi N, Sharma R. Management of coronary artery disease in patients with aortic stenosis in the era of transcatheter aortic valve replacement. Front Cardiovasc Med 2023; 10:1139360. [PMID: 37408653 PMCID: PMC10318168 DOI: 10.3389/fcvm.2023.1139360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023] Open
Abstract
Aortic stenosis (AS) is a common valve disorder among the elderly, and these patients frequently have concomitant coronary artery disease (CAD). Risk factors for calcific AS are similar to those for CAD. Historically, the treatment of these conditions involved simultaneous surgical replacement of the aortic valve (AV) with coronary artery bypass grafting. Since the advancement of transcatheter AV therapies, there have been tremendous advancements in the safety, efficacy, and feasibility of this procedure with expanding indications. This has led to a paradigm shift in our approach to the patient with AS and concomitant CAD. Data regarding the management of CAD in patients with AS are largely limited to single-center studies or retrospective analyses. This article aims to review available literature around the management of CAD in patients with AS and assist in the current understanding in approaches toward management.
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Affiliation(s)
- Agastya D. Belur
- Cardiovascular Disease Fellowship Program, University of Louisville School of Medicine, Louisville, KY, United States
| | - Naresh Solankhi
- Jewish Hospital Cardiology, University of Louisville Jewish Hospital, Louisville, KY, United States
| | - Ravi Sharma
- Jewish Hospital Cardiology, University of Louisville Jewish Hospital, Louisville, KY, United States
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Renker M, Steinbach R, Schoepf UJ, Fischer-Rasokat U, Choi YH, Hamm CW, Rolf A, Kim WK. Comparison of First-generation and Third-generation Dual-source Computed Tomography for Detecting Coronary Artery Disease in Patients Evaluated for Transcatheter Aortic Valve Replacement. J Thorac Imaging 2023; 38:165-173. [PMID: 37015832 DOI: 10.1097/rti.0000000000000699] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
PURPOSE This study compared image quality and evaluability of coronary artery disease (CAD) in routine preparatory imaging for transcatheter aortic valve replacement using 64-slice (first-generation) to 192-slice (third-generation) dual-source computed tomography(DSCT). MATERIALS AND METHODS The CT data sets of 192 patients (122 women, median age 82 y) without severe renal dysfunction or known CAD were analyzed retrospectively. Half were examined using first-generation DSCT (June 2014 to February 2016) and the other half with third-generation DSCT (April 2016 to April 2017). Per protocol, contrast material (110 [110 to 120] vs. 70 [70 to 70] mL, P <0.001) and radiation dose of multiphasic retrospectively gated thoracic CT angiography (dose-length-product, 1001 [707 to 1312] vs. 727 [474 to 1369] mGy×cm, P <0.001) were significantly lower with third-generation DSCT. Significant CAD was defined as CAD-RADS ≥4 by CT. Invasive coronary angiography served as the reference standard (CAD is defined as ≥70% stenosis or fractional flow reserve ≤0.80). RESULTS In comparison with first-generation DSCT, third-generation DSCT showed significantly better subjective (3 [interquartile range 2 to 3] vs. 4 [3 to 4.25] on a 5-point scale, P <0.001) and objective image quality (signal-to-noise ratio of left coronary artery 12.8 [9.9 to 16.4] vs. 15.2 [12.4 to 19.0], P <0.001). Accuracy (72.9% vs. 91.7%, P =0.001), specificity (59.7% vs. 88.3%, P <0.001), positive (61.0% vs. 83.3%, P <0.001), and negative predictive value (91.9% vs. 98.2%, P =0.045) for detecting CAD per-patient were significantly better using third-generation DSCT, while sensitivity was similar (92.3% vs. 97.2%, P =0.129). CONCLUSIONS Coronary artery evaluation with CT angiography before TAVI is feasible in selected patients. Compared with first-generation DSCT, state-of-the-art third-generation DSCT technology is superior for this purpose, allowing for less contrast medium and radiation dose while providing better image quality and improved diagnostic performance.
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Affiliation(s)
- Matthias Renker
- Departments of Cardiology
- Cardiac Surgery, Campus Kerckhoff of the Justus Liebig University Giessen, Bad Nauheim
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim
| | | | - U Joseph Schoepf
- Department of Radiology and Radiological Sciences, Heart and Vascular Center, Medical University of South Carolina, Charleston, SC
| | | | - Yeong-Hoon Choi
- Cardiac Surgery, Campus Kerckhoff of the Justus Liebig University Giessen, Bad Nauheim
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim
| | - Christian W Hamm
- Departments of Cardiology
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim
- Department of Radiology and Radiological Sciences, Heart and Vascular Center, Medical University of South Carolina, Charleston, SC
| | - Andreas Rolf
- Departments of Cardiology
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim
- Department of Radiology and Radiological Sciences, Heart and Vascular Center, Medical University of South Carolina, Charleston, SC
| | - Won-Keun Kim
- Departments of Cardiology
- Cardiac Surgery, Campus Kerckhoff of the Justus Liebig University Giessen, Bad Nauheim
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim
- Department of Radiology and Radiological Sciences, Heart and Vascular Center, Medical University of South Carolina, Charleston, SC
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Renker M, Schoepf UJ, Kim WK. Combined CT Coronary Artery Assessment and TAVI Planning. Diagnostics (Basel) 2023; 13:diagnostics13071327. [PMID: 37046545 PMCID: PMC10093468 DOI: 10.3390/diagnostics13071327] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/04/2023] [Accepted: 03/24/2023] [Indexed: 04/05/2023] Open
Abstract
Computed tomography angiography (CTA) of the aorta and the iliofemoral arteries is crucial for preprocedural planning of transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis (AS), because it provides details on a variety of aspects required for heart team decision-making. In addition to providing relevant diagnostic information on the degree of aortic valve calcification, CTA allows for a customized choice of the transcatheter heart valve system and the TAVI access route. Furthermore, current guidelines recommend the exclusion of relevant coronary artery disease (CAD) prior to TAVI. The feasibility of coronary artery assessment with CTA in patients scheduled for TAVI has been established previously, and accumulating data support its value. In addition, fractional flow reserve determined from CTA (CT–FFR) and machine learning-based CT–FFR were recently shown to improve its diagnostic yield for this purpose. However, the utilization of CTA for coronary artery evaluation remains limited in this specific population of patients due to the relatively high risk of CAD coexistence with severe AS. Therefore, the current diagnostic work-up prior to TAVI routinely includes invasive catheter coronary angiography at most centers. In this article, the authors address technological prerequisites and CT protocol considerations, discuss pitfalls, review the current literature regarding combined CTA coronary artery assessment and preprocedural TAVI evaluation, and provide an overview of unanswered questions and future research goals within the field.
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Affiliation(s)
- Matthias Renker
- Department of Cardiology, Campus Kerckhoff of the Justus Liebig University Giessen, 61231 Bad Nauheim, Germany
- Department of Cardiac Surgery, Campus Kerckhoff of the Justus Liebig University Giessen, 61231 Bad Nauheim, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Rhine-Main, 61231 Bad Nauheim, Germany
| | - U. Joseph Schoepf
- Heart & Vascular Center, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Won Keun Kim
- Department of Cardiology, Campus Kerckhoff of the Justus Liebig University Giessen, 61231 Bad Nauheim, Germany
- Department of Cardiac Surgery, Campus Kerckhoff of the Justus Liebig University Giessen, 61231 Bad Nauheim, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Rhine-Main, 61231 Bad Nauheim, Germany
- Department of Cardiology, Justus Liebig University Giessen, 35392 Giessen, Germany
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10
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Dobrolinska MM, Gąsior P, Błach A, Gocoł R, Hudziak D, Wojakowski W. Myocardial Perfusion and Coronary Physiology Assessment of Microvascular Dysfunction in Patients Undergoing Transcatheter Aortic Valve Implantation-Rationale and Design. Biomimetics (Basel) 2022; 7:biomimetics7040230. [PMID: 36546930 PMCID: PMC9775333 DOI: 10.3390/biomimetics7040230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
The prevalence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS) is 30-68%. Nevertheless, there is still not enough evidence to use invasive assessment of lesion severity, because the hemodynamic milieu of AS may impact the fractional flow reserve (FFR) and non-hyperemic indices. Therefore, the aim of the study is two-fold. First, to measure acute and long-term changes of FFR, index of microvascular resistance (IMR), and coronary flow reserve (CFR) in patients undergoing TAVI procedure. Second, to compare the diagnostic accuracy of intracoronary indices with myocardial perfusion measured by cadmium-zinc-telluride single-photon emission tomography (CZT-SPECT) and find cut-off values defining significant stenosis. We plan to enroll 40 patients eligible for TAVI with intermediate stenosis (30-70%) in the left anterior descending (LAD) coronary artery. In each patient FFR, CFR, and IMR will be measured in addition to myocardial blood flow calculated by CZT-SPECT before and either immediately after TAVI (acute cohort) or in 6 months (late cohort) after the procedure. FFR, CFR, and IMR will be matched with the results of myocardial perfusion measured by CZT-SPECT in the area of LAD. As a result, cut-off values of FFR, CFR, and IMR defining the decreased blood flow will be found.
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Affiliation(s)
- M. M. Dobrolinska
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, 40-635 Katowice, Poland
- Correspondence:
| | - P. Gąsior
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, 40-635 Katowice, Poland
| | - A. Błach
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, 40-635 Katowice, Poland
- Nuclear Medicine Department, Voxel Medical Diagnostic Centre, 40-635 Katowice, Poland
| | - R. Gocoł
- Department of Cardiac Surgery, Medical University of Silesia, 40-635 Katowice, Poland
| | - D. Hudziak
- Department of Cardiac Surgery, Medical University of Silesia, 40-635 Katowice, Poland
| | - W. Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, 40-635 Katowice, Poland
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11
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Peper J, Becker LM, van den Berg H, Bor WL, Brouwer J, Nijenhuis VJ, van Ginkel DJ, Rensing BJMW, Ten Berg JM, Timmers L, Leiner T, Swaans MJ. Diagnostic Performance of CCTA and CT-FFR for the Detection of CAD in TAVR Work-Up. JACC Cardiovasc Interv 2022; 15:1140-1149. [PMID: 35680194 DOI: 10.1016/j.jcin.2022.03.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/17/2022] [Accepted: 03/15/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The work-up for transcatheter aortic valve replacement (TAVR) currently uses computed tomography to evaluate the annulus diameter and peripheral vascular access plus invasive coronary angiography (ICA) to assess significant coronary artery disease (CAD). ICA might partially be redundant with the use of coronary computed tomography angiography (CCTA). Prior studies found an improvement of the diagnostic accuracy of CCTA with the use of computed tomography-derived fractional flow reserve (CT-FFR). OBJECTIVES The aim of this study was to assess the diagnostic performance of CT-FFR for the diagnosis of CAD in the work-up for TAVR. METHODS Consecutive patients with severe symptomatic aortic valve stenosis who underwent TAVR work-up between 2015 and 2019 were included in this retrospective cross-sectional study. All patients underwent CCTA and ICA within 3 months, and the diagnostic performance of both CCTA and CT-FFR was assessed using ICA as the reference. RESULTS Seventy-six of the 338 patients included in the analysis had ≥1 significant coronary stenosis on ICA. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy per patient were 76.9%, 64.5%, 34.0%, 92.1%, and 66.9% for CCTA and 84.6%, 88.3%, 63.2%, 96.0%, and 87.6% for CT-FFR. The area under the receiver-operating characteristic curve was significantly different between CCTA and CT-FFR (0.84 vs 0.90, P = 0.02). A CT-FFR-guided approach could avoid ICA in 57.1% versus 43.6% of patients using CCTA. CONCLUSIONS CT-FFR significantly improves the diagnostic accuracy of CCTA without additional testing and increases the proportion of patients in whom ICA could have been safely avoided. It has the potential to be integrated in the current clinical work-up for TAVR for diagnosing stable CAD requiring treatment.
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Affiliation(s)
- Joyce Peper
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Leonie M Becker
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hans van den Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Willem L Bor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jorn Brouwer
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Vincent J Nijenhuis
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Dirk-Jan van Ginkel
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Benno J M W Rensing
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jurrien M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Leo Timmers
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Tim Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
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12
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Keller LS, Panagides V, Mesnier J, Nuche J, Rodés-Cabau J. Percutaneous Coronary Intervention Pre-TAVR: Current State of the Evidence. Curr Cardiol Rep 2022; 24:1011-1020. [PMID: 35622221 DOI: 10.1007/s11886-022-01717-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW This review intends to give an up-to-date overview of the current state of evidence in the treatment of coronary artery disease (CAD) in patients undergoing transcatheter aortic valve replacement (TAVR), focusing on percutaneous coronary interventions (PCI) pre-TAVR. RECENT FINDINGS The recently published ACTIVATION trial is the 1st randomized trial comparing coronary revascularization (PCI) versus medical treatment in patients with significant CAD undergoing TAVR. With the caveat of several major limitations of the trial, the results of this study raised the question about the appropriateness of the common practice to routinely revascularize coronary stenosis before TAVR. Aortic valve stenosis is the most common valvular heart disease among the elderly and it often co-occurs with CAD. TAVR is increasingly considered an alternative to surgical aortic valve replacement not only in the elderly population but also in younger and lower-risk patients. The impact of co-existing CAD on clinical outcomes as well as the optimal timing of PCI in TAVR candidates is still unclear and the subject of ongoing randomized trials. Meanwhile, it is common practice in many centers to routinely perform invasive coronary angiography and PCI for significant coronary disease as part of the TAVR workup. While computed tomography angiography has emerged as a possible alternative to the invasive coronary angiography in patients with low pre-test probability for CAD, the value of functional invasive assessment of coronary lesions in the pre-TAVR setting has still to be clarified. Also, there is an increasing interest in the clinical relevance and optimal management of the potentially challenging coronary access post-TAVR, requiring further research.
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Affiliation(s)
- Lukas S Keller
- Québec Heart and Lung Institute, Laval University, 2725 Chemin Ste-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Vassili Panagides
- Québec Heart and Lung Institute, Laval University, 2725 Chemin Ste-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Jules Mesnier
- Québec Heart and Lung Institute, Laval University, 2725 Chemin Ste-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Jorge Nuche
- Québec Heart and Lung Institute, Laval University, 2725 Chemin Ste-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Josep Rodés-Cabau
- Québec Heart and Lung Institute, Laval University, 2725 Chemin Ste-Foy, Québec City, Québec, G1V 4G5, Canada.
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13
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Malebranche D, Hoffner MKM, Huber AT, Cicovic A, Spano G, Bernhard B, Bartkowiak J, Okuno T, Lanz J, Räber L, Praz F, Stortecky S, Windecker S, Pilgrim T, Gräni C. Diagnostic performance of quantitative coronary artery disease assessment using computed tomography in patients with aortic stenosis undergoing transcatheter aortic-valve implantation. BMC Cardiovasc Disord 2022; 22:178. [PMID: 35436856 PMCID: PMC9014581 DOI: 10.1186/s12872-022-02623-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 04/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Computed tomography angiography (CTA) is a cornerstone in the pre- transcatheter aortic valve replacement (TAVI) assessment. We evaluated the diagnostic performance of CTA and coronary artery calcium score (CACS) for CAD evaluation compared to invasive coronary angiography in a cohort of TAVI patients. METHODS In consecutive TAVI patients without prior coronary revascularization and device implants, CAD was assessment by quantitative analysis in CTA. (a) Patients with non-evaluable segments were classified as obstructive CAD. (b) In patients with non-evaluable segments a CACS cut-off of 100 was applied for obstructive CAD. The reference standard was quantitative invasive coronary angiography (QCA, i.e. ≥ 50% stenosis). RESULTS 100 consecutive patients were retrospectively included, age was 82.3 ± 6.5 years and 30% of patients had CAD. In 16% of the patients, adequate visualization of the entire coronary tree (all 16 segments) was possible with CTA, while 84% had at least one segment which was not evaluable for CAD analysis due to impaired image quality. On a per-patient analysis, where patients with low image quality were classified as CAD, CTA showed a sensitivity of 100% (95% CI 88.4-100.0), specificity of 11.4% (95% CI 5.1-21.3), PPV of 32.6% (95% CI 30.8-34.5), NPV of 100% and diagnostic accuracy of 38% (95% CI 28.5-48.3) for obstructive CAD. When applying a combined approach of CTA (in patients with good image quality) and CACS (in patients with low image quality), the sensitivity and NPV remained at 100% and obstructive CAD could be ruled out in 20% of the TAVI patients, versus 8% using CTA alone. CONCLUSION In routinely acquired pre-TAVI CTA, the image quality was insufficient in a high proportion of patients for the assessment of the entire coronary artery tree. However, when adding CACS in patients with low image quality to quantitative CTA assessment in patients with good image quality, obstructive CAD could be ruled-out in 1/5 of the patients and may therefore constitute a strategy to streamline pre-procedural workup, and reduce risk, radiation and costs in selected TAVI patients without prior coronary revascularization or device implants.
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Affiliation(s)
- Daniel Malebranche
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Maximilian K M Hoffner
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Adrian T Huber
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Aleksandar Cicovic
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Giancarlo Spano
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Joanna Bartkowiak
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Taishi Okuno
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
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14
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Feasibility and Comparison of Resting Full-Cycle Ratio and Computed Tomography Fractional Flow Reserve in Patients with Severe Aortic Valve Stenosis. J Cardiovasc Dev Dis 2022; 9:jcdd9040116. [PMID: 35448092 PMCID: PMC9030550 DOI: 10.3390/jcdd9040116] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 01/09/2023] Open
Abstract
Background: Computed tomography derived Fractional Flow Reserve (CT-FFR) has been shown to decrease the referral rate for invasive coronary angiography (ICA). The purpose of the study was to evaluate the diagnostic performance of CT-FFR compared to hyperemia-free index Resting Full-cycle Ratio (RFR) in patients with relevant aortic stenosis (AS) and intermediate coronary stenosis. Methods: 41 patients with 46 coronary lesions underwent ICA with quantitative coronary angiography (QCA), pressure wire assessment and routine pre-transcatheter aortic valve replacement (TAVR) computed tomography (CT). CT-FFR analysis was performed using prototype on-site software. Results: RFR showed a significant correlation with CT-FFR (Pearson’s correlation, r = 0.632, p < 0.001). On a per-lesion basis, diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CT-FFR were 82.6% (95% CI 68.6−92.2), 69.6% (95% CI 47.1−86.8), 95.7% (95% CI 78.1−99.9), 94.1% (95% CI 69.8−99.1), and 75.9% (95% CI 62.7−85.4), respectively. The optimal cutoff value of the CT-FFR for RFR ≤ 0.89 prediction was 0.815. The area under the receiver curve showed a larger area under the curve for CT-FFR (0.87; 95% CI 0.75−0.98) compared with CTA stenosis of ≥50% (0.54, 95% CI 0.38−0.71), CTA ≥ 70% (0.72, 95% CI 0.57−0.87) and QCA ≥ 50% (0.67, 95% CI 0.52−0.83). Conclusions: CT-FFR assessed by routine pre-TAVR CT is safe and feasible and shows a significant correlation with RFR in patients with AS. CT-FFR is superior to QCA ≥ 50%, CT ≥ 50% and CT ≥ 70% in assessing the hemodynamic relevance of intermediate coronary lesions. Thus, CT-FFR has the potential to guide revascularization in patients with AS.
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15
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Aleksandric S, Banovic M, Beleslin B. Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis. Front Cardiovasc Med 2022; 9:849032. [PMID: 35360024 PMCID: PMC8961810 DOI: 10.3389/fcvm.2022.849032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/16/2022] [Indexed: 01/10/2023] Open
Abstract
More than half of patients with severe aortic stenosis (AS) over 70 years old have coronary artery disease (CAD). Exertional angina is often present in AS-patients, even in the absence of significant CAD, as a result of oxygen supply/demand mismatch and exercise-induced myocardial ischemia. Moreover, persistent myocardial ischemia leads to extensive myocardial fibrosis and subsequent coronary microvascular dysfunction (CMD) which is defined as reduced coronary vasodilatory capacity below ischemic threshold. Therefore, angina, as well as noninvasive stress tests, have a low specificity and positive predictive value (PPV) for the assessment of epicardial coronary stenosis severity in AS-patients. Moreover, in symptomatic patients with severe AS exercise testing is even contraindicated. Given the limitations of noninvasive stress tests, coronary angiography remains the standard examination for determining the presence and severity of CAD in AS-patients, although angiography alone has poor accuracy in the evaluation of its functional severity. To overcome this limitation, the well-established invasive indices for the assessment of coronary stenosis severity, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), are now in focus, especially in the contemporary era with the rapid increment of transcatheter aortic valve replacement (TAVR) for the treatment of AS-patients. TAVR induces an immediate decrease in hyperemic microcirculatory resistance and a concomitant increase in hyperemic flow velocity, whereas resting coronary hemodynamics remain unaltered. These findings suggest that FFR may underestimate coronary stenosis severity in AS-patients, whereas iFR as the non-hyperemic index is independent of the AS severity. However, because resting coronary hemodynamics do not improve immediately after TAVR, the coronary vasodilatory capacity in AS-patients treated by TAVR remain impaired, and thus the iFR may overestimate coronary stenosis severity in these patients. The optimal method for evaluating myocardial ischemia in patients with AS and co-existing CAD has not yet been fully established, and this important issue is under further investigation. This review is focused on challenges, limitations, and future perspectives in the functional assessment of coronary stenosis severity in these patients, bearing in mind the complexity of coronary physiology in the presence of this valvular heart disease.
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Affiliation(s)
- Srdjan Aleksandric
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- *Correspondence: Srdjan Aleksandric
| | - Marko Banovic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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16
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Gohmann RF, Seitz P, Pawelka K, Majunke N, Schug A, Heiser L, Renatus K, Desch S, Lauten P, Holzhey D, Noack T, Wilde J, Kiefer P, Krieghoff C, Lücke C, Ebel S, Gottschling S, Borger MA, Thiele H, Panknin C, Abdel-Wahab M, Horn M, Gutberlet M. Combined Coronary CT-Angiography and TAVI Planning: Utility of CT-FFR in Patients with Morphologically Ruled-Out Obstructive Coronary Artery Disease. J Clin Med 2022; 11:jcm11051331. [PMID: 35268422 PMCID: PMC8910873 DOI: 10.3390/jcm11051331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Coronary artery disease (CAD) is a frequent comorbidity in patients undergoing transcatheter aortic valve implantation (TAVI). If significant CAD can be excluded on coronary CT-angiography (cCTA), invasive coronary angiography (ICA) may be avoided. However, a high plaque burden may make the exclusion of CAD challenging, particularly for less experienced readers. The objective was to analyze the ability of machine learning (ML)-based CT-derived fractional flow reserve (CT-FFR) to correctly categorize cCTA studies without obstructive CAD acquired during pre-TAVI evaluation and to correlate recategorization to image quality and coronary artery calcium score (CAC). Methods: In total, 116 patients without significant stenosis (≥50% diameter) on cCTA as part of pre-TAVI CT were included. Patients were examined with an electrocardiogram-gated CT scan of the heart and high-pitch scan of the torso. Patients were re-evaluated with ML-based CT-FFR (threshold = 0.80). The standard of reference was ICA. Image quality was assessed quantitatively and qualitatively. Results: ML-based CT-FFR was successfully performed in 94.0% (109/116) of patients, including 436 vessels. With CT-FFR, 76/109 patients and 126/436 vessels were falsely categorized as having significant CAD. With CT-FFR 2/2 patients but no vessels initially falsely classified by cCTA were correctly recategorized as having significant CAD. Reclassification occurred predominantly in distal segments. Virtually no correlation was found between image quality or CAC. Conclusions: Unselectively applied, CT-FFR may vastly increase the number of false positive ratings of CAD compared to morphological scoring. Recategorization was virtually independently from image quality or CAC and occurred predominantly in distal segments. It is unclear whether or not the reduced CT-FFR represent true pressure ratios and potentially signifies pathophysiology in patients with severe aortic stenosis.
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Affiliation(s)
- Robin Fabian Gohmann
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
- Correspondence: ; Tel.: +49-341-865-255-024
| | - Patrick Seitz
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
| | - Konrad Pawelka
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
| | - Nicolas Majunke
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (N.M.); (S.D.); (P.L.); (J.W.); (H.T.); (M.A.-W.)
| | - Adrian Schug
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
| | - Linda Heiser
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
| | - Katharina Renatus
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
| | - Steffen Desch
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (N.M.); (S.D.); (P.L.); (J.W.); (H.T.); (M.A.-W.)
| | - Philipp Lauten
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (N.M.); (S.D.); (P.L.); (J.W.); (H.T.); (M.A.-W.)
| | - David Holzhey
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (D.H.); (T.N.); (P.K.); (M.A.B.)
| | - Thilo Noack
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (D.H.); (T.N.); (P.K.); (M.A.B.)
| | - Johannes Wilde
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (N.M.); (S.D.); (P.L.); (J.W.); (H.T.); (M.A.-W.)
| | - Philipp Kiefer
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (D.H.); (T.N.); (P.K.); (M.A.B.)
| | - Christian Krieghoff
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
| | - Christian Lücke
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
| | - Sebastian Ebel
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
| | - Sebastian Gottschling
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
| | - Michael A. Borger
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (D.H.); (T.N.); (P.K.); (M.A.B.)
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (N.M.); (S.D.); (P.L.); (J.W.); (H.T.); (M.A.-W.)
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany
| | | | - Mohamed Abdel-Wahab
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (N.M.); (S.D.); (P.L.); (J.W.); (H.T.); (M.A.-W.)
| | - Matthias Horn
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Härtelstr. 16-18, 04107 Leipzig, Germany;
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany
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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. Eur Radiol 2022; 32:5189-5200. [PMID: 35192010 PMCID: PMC9279258 DOI: 10.1007/s00330-022-08603-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/02/2022] [Accepted: 01/19/2022] [Indexed: 11/04/2022]
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.
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Pontone G, Rossi A, Guglielmo M, Dweck MR, Gaemperli O, Nieman K, Pugliese F, Maurovich-Horvat P, Gimelli A, Cosyns B, Achenbach S. Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part II. Eur Heart J Cardiovasc Imaging 2022; 23:e136-e161. [PMID: 35175348 PMCID: PMC8944330 DOI: 10.1093/ehjci/jeab292] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/28/2021] [Indexed: 11/12/2022] Open
Abstract
Cardiac computed tomography (CT) was initially developed as a non-invasive diagnostic tool to detect and quantify coronary stenosis. Thanks to the rapid technological development, cardiac CT has become a comprehensive imaging modality which offers anatomical and functional information to guide patient management. This is the second of two complementary documents endorsed by the European Association of Cardiovascular Imaging aiming to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. In this article, emerging CT technologies and biomarkers, such as CT-derived fractional flow reserve, perfusion imaging, and pericoronary adipose tissue attenuation, are described. In addition, the role of cardiac CT in the evaluation of atherosclerotic plaque, cardiomyopathies, structural heart disease, and congenital heart disease is revised.
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Affiliation(s)
- Gianluca Pontone
- Corresponding author. Tel: +39 02 58002574; Fax: +39 02 58002231. E-mail:
| | | | - Marco Guglielmo
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Marc R Dweck
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Koen Nieman
- Department of Radiology and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francesca Pugliese
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Pal Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Alessia Gimelli
- Fondazione CNR/Regione Toscana “Gabriele Monasterio”, Pisa, Italy
| | - Bernard Cosyns
- Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, Universitair ziekenhuis Brussel, Brussel, Belgium
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-University of Erlangen, Erlangen, Germany
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de Azevedo Filho AF, Accorsi TA, Ribeiro HB. Coronary Artery Disease in Patients with Aortic Stenosis and Transcatheter Aortic Valve Implantation: Implications for Management. Eur Cardiol 2021; 16:e49. [PMID: 34950245 PMCID: PMC8674631 DOI: 10.15420/ecr.2021.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/16/2021] [Indexed: 01/09/2023] Open
Abstract
Aortic valve stenosis (AS) is the most common valvular heart disease among elderly patients. Since the pathophysiology of degenerative AS shares common pathways with atherosclerotic disease, the severity of AS in the elderly population is often concurrent to the presence of coronary artery disease (CAD). Although surgical aortic valve replacement has been the standard treatment for severe AS, the high operative morbidity and mortality in complex and fragile patients was the trigger to develop less invasive techniques. Transcatheter aortic valve implantation (TAVI) has been posed as the standard of care for elderly patients with severe AS with various risk profiles, which has meant that the concomitant management of CAD has become a crucial issue in such patients. Given the lack of randomised controlled trials evaluating the management of CAD in TAVI patients, most of the recommendations are based on retrospective cohort studies so that the Heart Team approach – together with an assessment of multiple parameters including symptoms and clinical characteristics, invasive and non-invasive ischaemic burden and anatomy – are crucial for the proper management of these patients. This article provides a review of current knowledge about assessment and therapeutic approaches for CAD and severe AS in patients undergoing TAVI.
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Affiliation(s)
| | - Tarso Ad Accorsi
- Department of Valvular Heart Disease, Heart Institute (InCor), University of São Paulo São Paulo, Brazil.,Samaritano Paulista Hospital São Paulo, Brazil
| | - Henrique B Ribeiro
- Samaritano Paulista Hospital São Paulo, Brazil.,Interventional Cardiology Department, Heart Institute (InCor), University of São Paulo São Paulo, Brazil
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Gohmann RF, Pawelka K, Seitz P, Majunke N, Heiser L, Renatus K, Desch S, Lauten P, Holzhey D, Noack T, Wilde J, Kiefer P, Krieghoff C, Lücke C, Gottschling S, Ebel S, Borger MA, Thiele H, Panknin C, Horn M, Abdel-Wahab M, Gutberlet M. Combined Coronary CT-Angiography and TAVR Planning for Ruling Out Significant Coronary Artery Disease: Added Value of Machine-Learning-Based CT-FFR. JACC Cardiovasc Imaging 2021; 15:476-486. [PMID: 34801449 DOI: 10.1016/j.jcmg.2021.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 09/07/2021] [Accepted: 09/10/2021] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To analyze the ability of machine-learning (ML)-based computed tomography (CT)-derived fractional flow reserve (CT-FFR) to further improve the diagnostic performance of coronary CT angiography (cCTA) for ruling out significant coronary artery disease (CAD) during pre-transcatheter aortic valve replacement (TAVR) evaluation in patients with a high pre-test probability for CAD. BACKGROUND CAD is a frequent comorbidity in patients undergoing TAVR. Current guidelines recommend its assessment before TAVR. If significant CAD can be excluded on cCTA, invasive coronary angiography (ICA) may be avoided. Although cCTA is a very sensitive test, it is limited by relatively low specificity and positive predictive value, particularly in high-risk patients. METHODS Overall, 460 patients (79.6 ± 7.4 years) undergoing pre-TAVR CT were included and examined with an electrocardiogram-gated CT scan of the heart and high-pitch scan of the vascular access route. Images were evaluated for significant CAD. Patients routinely underwent ICA (388/460), which was omitted at the discretion of the local Heart Team if CAD could be effectively ruled out on cCTA (72/460). CT examinations in which CAD could not be ruled out (CAD+) (n = 272) underwent additional ML-based CT-FFR. RESULTS ML-based CT-FFR was successfully performed in 79.4% (216/272) of all CAD+ patients and correctly reclassified 17 patients as CAD negative. CT-FFR was not feasible in 20.6% because of reduced image quality (37/56) or anatomic variants (19/56). Sensitivity, specificity, positive predictive value, and negative predictive value were 94.9%, 52.0%, 52.2%, and 94.9%, respectively. The additional evaluation with ML-based CT-FFR increased accuracy by Δ+3.4% (CAD+: Δ+6.0%) and raised the total number of examinations negative for CAD to 43.9% (202/460). CONCLUSIONS ML-based CT-FFR may further improve the diagnostic performance of cCTA by correctly reclassifying a considerable proportion of patients with morphological signs of obstructive CAD on cCTA during pre-TAVR evaluation. Thereby, CT-FFR has the potential to further reduce the need for ICA in this challenging elderly group of patients before TAVR.
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Affiliation(s)
- Robin F Gohmann
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany; Medical Faculty, University of Leipzig, Leipzig, Germany.
| | - Konrad Pawelka
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany; Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Patrick Seitz
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
| | - Nicolas Majunke
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Linda Heiser
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
| | - Katharina Renatus
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany; Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Steffen Desch
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Philipp Lauten
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - David Holzhey
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Thilo Noack
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Johannes Wilde
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Philipp Kiefer
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Christian Krieghoff
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
| | - Christian Lücke
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
| | - Sebastian Gottschling
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
| | - Sebastian Ebel
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany; Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Leipzig Heart Institute, Leipzig, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Leipzig Heart Institute, Leipzig, Germany
| | | | - Matthias Horn
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany
| | - Mohamed Abdel-Wahab
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany; Medical Faculty, University of Leipzig, Leipzig, Germany; Leipzig Heart Institute, Leipzig, Germany
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Image quality and diagnostic performance evaluation in transcatheter aortic valve implantation candidates with atrial fibrillation using a whole-heart coverage CT scanner. Eur Radiol 2021; 32:1034-1043. [PMID: 34338842 DOI: 10.1007/s00330-021-08187-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/09/2021] [Accepted: 06/29/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the image quality and diagnostic performance for obstructive coronary artery disease of transcatheter aortic valve implantation (TAVI) patients with atrial fibrillation (AF) during TAVI planning CT using a whole-heart coverage CT scanner. METHODS Eighty-eight consecutive TAVI candidates with AF (50 men, 74 ± 6 years) who underwent both TAVI planning CT and invasive coronary catheter angiography (ICA) were retrospectively analyzed. With ICA results as the reference standard, the accuracy of TAVI planning CT for lesion detection on a per-vessel and per-patient level was calculated. Meanwhile, image quality, contrast volume, and effective dose (ED) were evaluated. A 5-point visual scale (1-5) was used to assess the subjective image quality. The CT value and signal-to-noise ratio were measured for the left main coronary artery (LM), left anterior descending (LAD), left circumflex (LCX), and right coronary arteries (RCA). RESULTS The ED for CCTA was 3.25 ± 1.39 mSv and contrast volume was 58.14 ± 12.34 mL. A total of 1371 (1371/1408 = 97.4%) segments with diameter > 1.5 mm were analyzed. For the subjective evaluation, the mean score was 3.99 ± 0.96 for overall image quality. The mean CT values in LM, RCA, LCX, and LAD were all above 400 HU. For the detection of > 50% stenosis, TAVI planning CT provided on the per-vessel and per-patient basis 97.06% and 100% in sensitivity, 96.23% and 89.06% in specificity, 99.7% and 100% in negative predictive value, and 73.3% and 77.4% in positive predictive value, respectively. CONCLUSION TAVI planning CT with whole-heart coverage demonstrates good CCTA image quality and a high sensitivity and NPV in excluding obstructive CAD in TAVI candidates with AF. KEY POINTS • Transcatheter aortic valve implantation planning (TAVI) CT with whole-heart coverage enables good image quality of CCTA in TAVI candidates with atrial fibrillation. • Obstructive coronary artery disease may be excluded with high accuracy in transcatheter aortic valve implantation (TAVI) candidates with atrial fibrillation with the usage of whole-heart coverage TAVI planning CT.
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Seitz P, Krieghoff C, Gottschling S, Lücke C, Abdel-Wahab M, Holzhey D, Gohmann RF, Gutberlet M. Pre-procedural high-pitch coronary CT angiography assessment of patients undergoing transcatheter aortic valve implantation (TAVI) without patient-specific adjustment: analysis of diagnostic performance. Clin Radiol 2021; 76:862.e29-862.e36. [PMID: 34261598 DOI: 10.1016/j.crad.2021.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/15/2021] [Indexed: 11/20/2022]
Abstract
AIM To evaluate the ability to assess the coronary arteries using pre-procedural computed tomography (CT; high-pitch mode) in patients referred for transcatheter aortic valve implantation (TAVI). METHODS AND MATERIALS CT and invasive coronary angiography (ICA) were performed pre-TAVI in 100 patients (46 women; 79 ± 5.9 years). CT was performed in prospectively ECG-triggered high-pitch mode after intravenous administration of 70 ml iodinated contrast medium. Image quality was assessed using a four-point scale (graded 0-3). Significant coronary artery stenosis (≥50% diameter) was graded as either present or absent by one observer and in one-third of patients by two observers independently. ICA was the standard of reference. Results were reported per segment and per patient. RESULTS Twenty-two percent of patients had known coronary artery disease (CAD). In two cases, a coronary anomaly was detected. Diagnostic image quality (grade 1-3) was achieved in 30.3% of segments. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 75%, 80.5%, 16%, and 98.5%, respectively. Significant coronary stenosis could be ruled out completely in all segments in three patients. The interrater agreement per patient was excellent (kappa = 1). CONCLUSION Relevant coronary findings can frequently be observed in high-pitch TAVI-planning CT. Despite the limitations of the technique and in patients referred to pre-TAVI evaluation (rapid heart rate, coronary calcifications, etc.), a valid evaluation of coronary arteries is possible in a considerable proportion of segments with a high NPV; however, few studies were completely free of motion artefacts to dependably exclude CAD using this technique in this challenging group of patients.
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Affiliation(s)
- P Seitz
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany.
| | - C Krieghoff
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - S Gottschling
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - C Lücke
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - M Abdel-Wahab
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany; Leipzig Heart Institute, Russenstraße 69a, 04289, Leipzig, Germany
| | - D Holzhey
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - R F Gohmann
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany; Medical Faculty, University of Leipzig, Liebigstraße 27, 04103, Leipzig, Germany
| | - M Gutberlet
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany; Leipzig Heart Institute, Russenstraße 69a, 04289, Leipzig, Germany; Medical Faculty, University of Leipzig, Liebigstraße 27, 04103, Leipzig, Germany
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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). Eur Radiol 2021; 32:143-151. [PMID: 34132873 PMCID: PMC8660749 DOI: 10.1007/s00330-021-08095-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 05/12/2021] [Accepted: 05/25/2021] [Indexed: 11/24/2022]
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. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08095-2.
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Lind AY, Totzeck M, Rassaf T, Jánosi RA. [Aortic stenosis - Selection of the appropriate TAVR patient]. MMW Fortschr Med 2021; 163:46-53. [PMID: 33844225 DOI: 10.1007/s15006-021-9714-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Alexander Y Lind
- Klinik für Kardiologie und Angiologie, Westdeutsches Herz- und Gefäßzentrum,, UniversitätDuisburg-Essen, Hufelandstraße 55, D-45147, Essen, Germany
| | - Matthias Totzeck
- - Klinik f. Kardiologie u. Angilogie -, Westdt.Herz- u. Gefäßzentrum\/Univ.-Klinikum Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Tienush Rassaf
- - Universitätsklinikum Essen -, Westdt. Herz- u. Gefäßzentrum\/Klinik f. Kardiologie, Hufelandstr. 55, 45122, Essen, Germany
| | - R Alexander Jánosi
- Klinik für Kardiologie und Angiologie, Westdeutsches Herz- und Gefäßzentrum, Universität Duisburg-Essen, Hufelandstraße 55, D-45147, Essen, Germany
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Aortic Valve Disease and Associated Complex CAD: The Interventional Approach. J Clin Med 2021; 10:jcm10050946. [PMID: 33804391 PMCID: PMC7957505 DOI: 10.3390/jcm10050946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/19/2021] [Accepted: 02/20/2021] [Indexed: 01/09/2023] Open
Abstract
Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis (AS). The management of CAD is a central aspect of the work-up of patients undergoing transcatheter aortic valve implantation (TAVI), but few data are available on this field and the best percutaneous coronary intervention (PCI) practice is yet to be determined. A major challenge is the ability to elucidate the severity of bystander coronary stenosis independently of the severity of aortic valve stenosis and subsequent impact on blood flow. The prognostic role of CAD in patients undergoing TAVI is being still debated and the benefits and the best timing of PCI in this context are currently under evaluation. Additionally, PCI in the setting of advanced AS poses some technical challenges, due to the complex anatomy, risk of hemodynamic instability, and the increased risk of bleeding complications. This review aims to provide a comprehensive synthesis of the available literature on myocardial revascularization in patients with severe AS undergoing TAVI. This work can assist the Heart Team in individualizing decisions about myocardial revascularization, taking into account available diagnostic tools as well as the risks and benefits.
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Meier D, Depierre A, Topolsky A, Roguelov C, Dupré M, Rubimbura V, Eeckhout E, Qanadli SD, Muller O, Mahendiran T, Rotzinger D, Fournier S. Computed Tomography Angiography for the Diagnosis of Coronary Artery Disease Among Patients Undergoing Transcatheter Aortic Valve Implantation. J Cardiovasc Transl Res 2021; 14:894-901. [PMID: 33543417 PMCID: PMC8575747 DOI: 10.1007/s12265-021-10099-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 01/05/2021] [Indexed: 11/05/2022]
Abstract
Background Computed tomography angiography (CTA) is used to plan TAVI procedures. We investigated the performance of pre-TAVI CTA for excluding coronary artery disease (CAD). Methods In total 127 patients were included. CTA images were analyzed for the presence of ≥ 50% (significant CAD) and ≥ 70% (severe CAD) diameter stenoses in proximal coronary arteries. Results were compared with invasive coronary angiography (ICA) at vessel and patient levels. Primary endpoint was the negative predictive value (NPV) of CTA for the presence of CAD. Results A total of 342 vessels were analyzable. NPV of CTA was 97.5% for significant CAD and 96.3% for severe CAD. Positive predictive value and accuracy were 44.8% and 87.1% for significant CAD and 56.3% and 94.4% for severe CAD. At patient level, NPV for significant CAD was 88.6%. Conclusion Pre-TAVI CTA shows good performance for ruling out CAD and could be used as a gatekeeper for ICA in selected patients. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s12265-021-10099-8.
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Affiliation(s)
- David Meier
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland
| | - Arnaud Depierre
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland
| | - Antoine Topolsky
- Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland.,Department of Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Christan Roguelov
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland
| | - Marion Dupré
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland
| | - Vladimir Rubimbura
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland
| | - Eric Eeckhout
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland
| | - Salah Dine Qanadli
- Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland.,Department of Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland
| | - Thabo Mahendiran
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland
| | - David Rotzinger
- Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland. .,Department of Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Stephane Fournier
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland. .,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland. .,Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 522] [Impact Index Per Article: 174.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 721] [Impact Index Per Article: 240.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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30
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e35-e71. [PMID: 33332149 DOI: 10.1161/cir.0000000000000932] [Citation(s) in RCA: 320] [Impact Index Per Article: 106.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2021; 77:450-500. [DOI: 10.1016/j.jacc.2020.11.035] [Citation(s) in RCA: 272] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Toia P, La Grutta L, Smeraldi T, Agnello F, Grassedonio E, Maffei E, Midiri M, Cademartiri F. Updated diagnostic & prognostic paradigm for CAD: a narrative review. Cardiovasc Diagn Ther 2020; 10:1979-1991. [PMID: 33381438 PMCID: PMC7758757 DOI: 10.21037/cdt-20-526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/23/2020] [Indexed: 12/24/2022]
Abstract
Cardiovascular diseases are the first cause of death globally; early detection of coronary artery disease (CAD) is a challenge for clinicians and radiologists. Over the past 2 decades there have been several improvements in the methods for the assessment of diagnosis and prognosis in patients with suspected CAD; most of these methods are imaging methods and they operate with high-end technologies. Cardiac computed tomography (CCT) as we know it today was introduced in 1998 and has ever progressed with constant pace. The first decade was the technical validation phase of the method while the second decade was the clinical validation phase. CCT has developed an excellent diagnostic and prognostic value; technological development together with radiation dose reduction, contributed to the widening of its clinical indications. The diagnostic value of CCT is particularly important as a first line in symptomatic patients with suspected obstructive CAD and low-to-intermediate cardiovascular risk. It is a test that should come, whenever possible, in front of functional evaluation because of its very high sensitivity and negative predictive value. The prognostic value of CCt is still investigational, even though it is becoming quite evident that the atherosclerotic phenotype plays a major role in the determination of prognosis, and as consequence, in the individualization of optimal pharmacological therapy, especially in the cohort without significant obstructive CAD. Recently, scientific and practical guidelines have been updated taking into account the role of CCT, which is able to provide a reliable and fast diagnosis with an additional resources optimization. Multiple registries and trials have been developed and will be summarized in this review. Recent guidelines highlighted the role of CCT in diagnosing suspected CAD.
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Affiliation(s)
- Patrizia Toia
- Department of Biomedicine, Neurosciences and Advanced Diagnostic (BiND), University of Palermo, Italy
| | - Ludovico La Grutta
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialities (ProMISE), University of Palermo, Italy
| | - Tommaso Smeraldi
- Department of Biomedicine, Neurosciences and Advanced Diagnostic (BiND), University of Palermo, Italy
| | - Francesco Agnello
- Department of Biomedicine, Neurosciences and Advanced Diagnostic (BiND), University of Palermo, Italy
| | - Emanuele Grassedonio
- Department of Biomedicine, Neurosciences and Advanced Diagnostic (BiND), University of Palermo, Italy
| | - Erica Maffei
- Department of Radiology, Area Vasta 1, ASUR Marche, Urbino (PU), Italy
| | - Massimo Midiri
- Department of Biomedicine, Neurosciences and Advanced Diagnostic (BiND), University of Palermo, Italy
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TAVI imaging: over the echocardiography. Radiol Med 2020; 125:1148-1166. [DOI: 10.1007/s11547-020-01281-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/03/2020] [Indexed: 12/26/2022]
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Gohmann RF, Lauten P, Seitz P, Krieghoff C, Lücke C, Gottschling S, Mende M, Weiß S, Wilde J, Kiefer P, Noack T, Desch S, Holzhey D, Borger MA, Thiele H, Abdel-Wahab M, Gutberlet M. Combined Coronary CT-Angiography and TAVI-Planning: A Contrast-Neutral Routine Approach for Ruling-out Significant Coronary Artery Disease. J Clin Med 2020; 9:jcm9061623. [PMID: 32471233 PMCID: PMC7356559 DOI: 10.3390/jcm9061623] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/15/2020] [Accepted: 05/22/2020] [Indexed: 01/20/2023] Open
Abstract
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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Affiliation(s)
- Robin F. Gohmann
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (C.K.); (C.L.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
- Correspondence: ; Tel.: +49-341-865-255-024
| | - Philipp Lauten
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.L.); (J.W.); (S.D.); (H.T.); (M.A.-W.)
| | - Patrick Seitz
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (C.K.); (C.L.); (S.G.); (M.G.)
| | - Christian Krieghoff
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (C.K.); (C.L.); (S.G.); (M.G.)
| | - Christian Lücke
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (C.K.); (C.L.); (S.G.); (M.G.)
| | - Sebastian Gottschling
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (C.K.); (C.L.); (S.G.); (M.G.)
| | - Meinhard Mende
- Institute of Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Härtelstr. 16-18, 04107 Leipzig, Germany;
| | - Stefan Weiß
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany; (S.W.); (M.A.B.)
| | - Johannes Wilde
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.L.); (J.W.); (S.D.); (H.T.); (M.A.-W.)
| | - Philipp Kiefer
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.K.); (T.N.); (D.H.)
| | - Thilo Noack
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.K.); (T.N.); (D.H.)
| | - Steffen Desch
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.L.); (J.W.); (S.D.); (H.T.); (M.A.-W.)
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany; (S.W.); (M.A.B.)
| | - David Holzhey
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.K.); (T.N.); (D.H.)
| | - Michael A. Borger
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany; (S.W.); (M.A.B.)
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.K.); (T.N.); (D.H.)
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.L.); (J.W.); (S.D.); (H.T.); (M.A.-W.)
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany; (S.W.); (M.A.B.)
| | - Mohamed Abdel-Wahab
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.L.); (J.W.); (S.D.); (H.T.); (M.A.-W.)
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany; (S.W.); (M.A.B.)
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (C.K.); (C.L.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany; (S.W.); (M.A.B.)
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Coronary Artery Disease and Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 74:362-372. [PMID: 31319919 DOI: 10.1016/j.jacc.2019.06.012] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 01/09/2023]
Abstract
About one-half of transcatheter aortic valve replacement (TAVR) candidates have coronary artery disease (CAD), and controversial results have been reported regarding the effect of the presence and severity of CAD on clinical outcomes post-TAVR. In addition to coronary angiography, promising data has been recently reported on both the use of computed tomography angiography and the functional invasive assessment of coronary lesions in the work-up pre-TAVR. While waiting for the results of ongoing randomized trials, percutaneous revascularization of significant coronary lesions has been the routine strategy in TAVR candidates with CAD. Also, scarce data exists on the incidence, characteristics, and management of coronary events post-TAVR, and increasing interest exist on potential coronary access challenges in patients requiring coronary angiography/intervention post-TAVR. This review provides an updated overview of the current landscape of CAD in TAVR recipients, focusing on its prevalence, clinical impact, pre- and post-procedural evaluation and management, unresolved issues and future perspectives.
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Barth S, Hautmann MB, Reents W, Zacher M, Griese DP, Kerber S, Diegeler A, Hamm K. Transcatheter aortic valve replacement for severe aortic stenosis can improve long-term survival of nonagenarians as compared to an age- and sex-matched general population. J Cardiol 2020; 75:134-139. [DOI: 10.1016/j.jjcc.2019.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/26/2019] [Accepted: 07/18/2019] [Indexed: 11/28/2022]
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Third generation dual source CT with ultra-high pitch protocol for TAVI planning and coronary tree assessment: feasibility, image quality and diagnostic performance. Eur J Radiol 2020; 122:108749. [DOI: 10.1016/j.ejrad.2019.108749] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 11/07/2019] [Accepted: 11/12/2019] [Indexed: 01/14/2023]
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Strong C, Ferreira A, Teles RC, Mendes G, Abecasis J, Cardoso G, Guerreiro S, Freitas P, Santos AC, Saraiva C, Brito J, Raposo L, Gonçalves PDA, Gabriel HM, Almeida MDS, Mendes M. Diagnostic accuracy of computed tomography angiography for the exclusion of coronary artery disease in candidates for transcatheter aortic valve implantation. Sci Rep 2019; 9:19942. [PMID: 31882777 PMCID: PMC6934755 DOI: 10.1038/s41598-019-56519-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/10/2019] [Indexed: 01/02/2023] Open
Abstract
Coronary CT angiography (CTA) is currently considered a reliable method to exclude obstructive coronary artery disease (CAD) before valvular heart surgery in patients with low pretest probability. However, its role in excluding obstructive CAD before transcatheter aortic valve implantation (TAVI) is less well established. Single-center retrospective study where patients with severe symptomatic aortic stenosis underwent both CTA and invasive coronary angiography (ICA) as part of TAVI planning. CTA exams were conducted on a 64-slice dual source scanner, with a median interval of 45 days to ICA (IQR 25–75 [13–82]). In both tests, obstructive CAD was defined as a ≥50% stenosis in an epicardial vessel ≥2 mm diameter. Per-patient, per-vessel and per-proximal segment analyses were conducted, excluding and including non-evaluable segments. The study included 200 patients (120 women, mean age 83 ± 6 years). The prevalence of obstructive CAD on ICA was 35.5% (n = 71). On a per-patient analysis (assuming non-evaluable segments as stenotic), CTA showed sensitivity of 100% (95% CI, 95–100%), specificity of 42% (95% CI, 33–51%), and positive and negative predictive values of 48% (95% CI, 44–51%) and 100% (95% CI, 92–100%), respectively. CTA was able to exclude obstructive CAD in 54 patients (27%), in whom ICA could have been safely withheld. Despite the high rate of inconclusive tests, pre-procedural CTA is able to safely exclude obstructive CAD in a significant proportion of patients undergoing TAVI, possibly avoiding the need for ICA in roughly one quarter of the cases.
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Affiliation(s)
- Christopher Strong
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal.
| | - António Ferreira
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - Rui Campante Teles
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - Gustavo Mendes
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - João Abecasis
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - Gonçalo Cardoso
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - Sara Guerreiro
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - Pedro Freitas
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | | | - Carla Saraiva
- Hospital de Santa Cruz, Radiology department, Lisboa, 2790-134, Portugal
| | - João Brito
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - Luís Raposo
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | | | | | | | - Miguel Mendes
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
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Blanke P, Weir-McCall JR, Achenbach S, Delgado V, Hausleiter J, Jilaihawi H, Marwan M, Norgaard BL, Piazza N, Schoenhagen P, Leipsic JA. Computed tomography imaging in the context of transcatheter aortic valve implantation (TAVI) / transcatheter aortic valve replacement (TAVR): An expert consensus document of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2019; 13:1-20. [DOI: 10.1016/j.jcct.2018.11.008] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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40
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Blanke P, Weir-McCall JR, Achenbach S, Delgado V, Hausleiter J, Jilaihawi H, Marwan M, Nørgaard BL, Piazza N, Schoenhagen P, Leipsic JA. Computed Tomography Imaging in the Context of Transcatheter Aortic Valve Implantation (TAVI)/Transcatheter Aortic Valve Replacement (TAVR). JACC Cardiovasc Imaging 2019; 12:1-24. [DOI: 10.1016/j.jcmg.2018.12.003] [Citation(s) in RCA: 192] [Impact Index Per Article: 38.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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van den Boogert TPW, Vendrik J, Claessen BEPM, Baan J, Beijk MA, Limpens J, Boekholdt SAM, Hoek R, Planken RN, Henriques JP. CTCA for detection of significant coronary artery disease in routine TAVI work-up : A systematic review and meta-analysis. Neth Heart J 2018; 26:591-599. [PMID: 30178209 PMCID: PMC6288031 DOI: 10.1007/s12471-018-1149-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has evolved to standard treatment of severe aortic stenosis in patients with an intermediate to high surgical risk. Computed tomography coronary angiography (CTCA) could partially replace invasive coronary angiography to diagnose significant coronary artery disease in the work-up for TAVI. A literature search was performed in MEDLINE and EMBASE for papers comparing CTCA and coronary angiography in TAVI candidates. The primary endpoint was the diagnostic accuracy of CTCA, compared to coronary angiography, for detection of significant (>50% diameter stenosis) coronary artery disease, measured as sensitivity, specificity, positive—(PPV) and negative predictive value (NPV). Seven studies were included, with a cumulative sample size of 1,275 patients. The patient-based pooled sensitivity, specificity, PPV and NPV were 95, 65, 71 and 94% respectively. Quality assessment revealed excellent and good quality in terms of applicability and risk of bias respectively, with the main concern being patient selection. In conclusion, on the basis of a significance cut-off value of 50% diameter stenosis, CTCA provides acceptable diagnostic accuracy for the exclusion of coronary artery disease in patients referred for TAVI. Using the routinely performed preoperative computed tomography scans as a gatekeeper for coronary angiography could decrease additional coronary angiographies by 37% in this high-risk and fragile population.
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Affiliation(s)
- T P W van den Boogert
- Heart Centre, Academic Medical Centre, part of the Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - J Vendrik
- Heart Centre, Academic Medical Centre, part of the Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - B E P M Claessen
- Heart Centre, Academic Medical Centre, part of the Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - J Baan
- Heart Centre, Academic Medical Centre, part of the Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - M A Beijk
- Heart Centre, Academic Medical Centre, part of the Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - J Limpens
- Medical Library, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - S A M Boekholdt
- Heart Centre, Academic Medical Centre, part of the Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - R Hoek
- Heart Centre, Academic Medical Centre, part of the Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - R N Planken
- Department of Radiology and Nuclear Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - J P Henriques
- Heart Centre, Academic Medical Centre, part of the Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands.
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Chaikriangkrai K, Jhun HY, Shantha GPS, Abdulhak AB, Tandon R, Alqasrawi M, Klappa A, Pancholy S, Deshmukh A, Bhama J, Sigurdsson G. Diagnostic Accuracy of Coronary Computed Tomography Before Aortic Valve Replacement: Systematic Review and Meta-Analysis. J Thorac Imaging 2018; 33:207-216. [PMID: 29389809 DOI: 10.1097/rti.0000000000000322] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE In aortic stenosis patients referred for surgical and transcatheter aortic valve replacement (AVR), the evidence of diagnostic accuracy of coronary computed tomography angiography (CCTA) has been limited. The objective of this study was to investigate the diagnostic accuracy of CCTA for significant coronary artery disease (CAD) in patients referred for AVR using invasive coronary angiography (ICA) as the gold standard. MATERIALS AND METHODS We searched databases for all diagnostic studies of CCTA in patients referred for AVR, which reported diagnostic testing characteristics on patient-based analysis required to pool summary sensitivity, specificity, positive-likelihood ratio, and negative-likelihood ratio. Significant CAD in both CCTA and ICA was defined by >50% stenosis in any coronary artery, coronary stent, or bypass graft. RESULTS Thirteen studies evaluated 1498 patients (mean age, 74 y; 47% men; 76% transcatheter AVR). The pooled prevalence of significant stenosis determined by ICA was 43%. Hierarchical summary receiver-operating characteristic analysis demonstrated a summary area under curve of 0.96. The pooled sensitivity, specificity, and positive-likelihood and negative-likelihood ratios of CCTA in identifying significant stenosis determined by ICA were 95%, 79%, 4.48, and 0.06, respectively. In subgroup analysis, the diagnostic profiles of CCTA were comparable between surgical and transcatheter AVR. CONCLUSIONS Despite the higher prevalence of significant CAD in patients with aortic stenosis than with other valvular heart diseases, our meta-analysis has shown that CCTA has a suitable diagnostic accuracy profile as a gatekeeper test for ICA. Our study illustrates a need for further study of the potential role of CCTA in preoperative planning for AVR.
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Affiliation(s)
| | - Hye Yeon Jhun
- Department of Medicine, University of Kansas Medical Center, Kansas City, KS
| | | | - Aref Bin Abdulhak
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Rudhir Tandon
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Musab Alqasrawi
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Anthony Klappa
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Samir Pancholy
- The Wright Center for Graduate Medical Education, Scranton, PA
| | | | - Jay Bhama
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Gardar Sigurdsson
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA
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Rodriguez-Granillo GA, Reynoso E, Capunay C, Carpio J, Carrascosa P. Pericardial and visceral, but not total body fat, are related to global coronary and extra-coronary atherosclerotic plaque burden. Int J Cardiol 2018; 260:204-210. [DOI: 10.1016/j.ijcard.2018.01.106] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/08/2018] [Accepted: 01/22/2018] [Indexed: 01/12/2023]
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Leipsic J, Bax JJ, Webb JG, Martin R, Blanke P. Trials Testing the Value of Imaging Use in Valve Disease and in Transcatheter Valvular Interventions. JACC Cardiovasc Imaging 2017; 10:286-295. [PMID: 28279376 DOI: 10.1016/j.jcmg.2016.09.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 09/19/2016] [Accepted: 09/22/2016] [Indexed: 12/20/2022]
Abstract
The role of imaging in the diagnosis of valvular heart disease is well established through years of investigation and validation. However, the role of imaging in guiding the treatment decision-making for valvular heart disease is less well established, and there is a striking paucity of randomized trial data to help inform these decisions. Given this relative absence of randomized trial data, the present article highlights some of the most important knowledge gaps and defines meaningful opportunities for the field to help advance the care of patients with valvular heart disease in a cost-effective fashion. (The PARTNER 3-Trial: The Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients With Aortic Stenosis [P3]; NCT02675114; Medtronic Transcatheter Aortic Valve Replacement in Low Risk Patients; NCT02701283).
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Affiliation(s)
- Jonathon Leipsic
- Department of Radiology and Cardiology, Centre for Heart Valve Innovation, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Jeroen J Bax
- Leiden University Medical Center, Leiden, the Netherlands
| | - John G Webb
- Department of Radiology and Cardiology, Centre for Heart Valve Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Philipp Blanke
- Department of Radiology and Cardiology, Centre for Heart Valve Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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Comparison of outcomes using balloon-expandable versus self-expanding transcatheter prostheses according to the extent of aortic valve calcification. Clin Res Cardiol 2017; 106:995-1004. [PMID: 28795259 DOI: 10.1007/s00392-017-1149-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 08/02/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Device landing zone (DLZ) calcification is an important determinant of procedural success in transcatheter aortic valve implantation (TAVI). OBJECTIVE To evaluate the impact of DLZ calcification on procedural outcome with different types of transcatheter heart valves (THVs). METHODS Aortic valve calcium density (AVCdens) was determined by non-contrast-enhanced computed tomography in 1232 patients undergoing transfemoral TAVI. We stratified the outcome data according to the extent of AVCdens (mild, moderate, severe) and compared balloon-expandable (BE) with self-expanding (SE) THV. Moreover, THVs were subdivided according to their radial force (BE: high; SEmod: moderate; SElow: low). RESULTS With BE THV, PVR ≥2° (2.1 vs. 7.9%; p < 0.001), post-dilatation (12.3 vs. 36.6%; p < 0.001), malpositioning (8.4 vs. 13.0%; p = 0.01), device embolization (0.4 vs. 2.6%; p = 0.004), and the need for a second valve (1.2 vs. 3.6%; p = 0.01) were less frequent than with SE devices, but mean transaortic gradients at discharge were higher [12.0 mmHg (8.0-15.0) vs. 9.0 mmHg (6.0-11.0); p < 0.001], and aortic root injury was more frequent (2.7 vs. 0.8%; p = 0.01). In cases of severe calcification, differences between BE and SE THV regarding PVR, post-dilatation, and hemodynamics were mostly pronounced, followed by patients with moderate AVCdens. In cases with low AVCdens, the best outcomes with respect to PVR, pacemaker implantation, and hemodynamics were achieved with SElow THV. CONCLUSIONS In severe and moderate DLZ calcification, BE devices may have advantages, whereas in mild DLZ calcification, SElow THV showed the most favorable profile.
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Declining radiation dose of coronary computed tomography angiography: German cardiac CT registry experience 2009-2014. Clin Res Cardiol 2017; 106:905-912. [PMID: 28725938 DOI: 10.1007/s00392-017-1136-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 07/17/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Coronary computed tomography angiography (CTA) is increasingly used as a test to rule out coronary artery disease (CAD) in patients with a low to intermediate pre-test probability of the disease. We used the database of the German CT registry, collected between 2009 and 2014 in a broad patient population, to analyze contemporary radiation dose associated with coronary CTA in clinical practice. PATIENTS AND METHODS The prospective observational registry included a total of 7061 patients ≥18 years, referred to 12 participating centers for a clinically indicated cardiac CT examination. All centers were cardiology units well experienced in CTA and used multi-slice CT scanners with at least 64 rows. Coronary CTA was performed in a subset of 5001 patients, 59.6 ± 11.8 years, body mass index (BMI) 26.9 ± 4.5 kg/m2, 38% females. Three time periods with approximately equal numbers of patients were created (01/09-03/10, 04/10-03/11, 04/11-07/14). The dose-length product of all examinations and derived effective dose in mSv (conversion factor k = 0.014) as well as the influence of patient characteristics on dose were compared for the three time periods. RESULTS BMI and proportion of female patients remained stable over time, and mean heart rate decreased from 60.3 ± 9.0 to 58.5 ± 9.3 bpm from the first to the last time period (p < 0.001). Overall, the mean effective dose of coronary CTA was 3.6 mSv (Q1 1.8 mSv, Q3 7.4 mSv). Within the three time periods, it declined from 5.6 (2.7, 8.6) mSv during the first to 4.8 (2.1, 8.2) mSv during the second and 2.5 (1.3, 4.6) mSv during the last time period (p < 0.001). Paralleling the decline in radiation dose over time, the proportion of prospectively ECG-triggered examinations increased (68, 79, 83%; p < 0.001), and the proportion of examinations with retrospective gating and no tube current modulation decreased (5.3, 4.0, 1.6%; p < 0.001). Tube current (mAs) and voltage (kV) both decreased over time. In multivariable analysis, besides earlier time period, further independent predictors of an increased radiation dose were older age, higher heart rate, and higher BMI as well as the technical factors higher mAs, higher kV, and retrospective gating. At three sites, CT scanners with improved technology were installed during the last time period. CONCLUSIONS In current clinical practice among German cardiology units with specific expertise in cross-sectional cardiovascular imaging, overall radiation dose of coronary CTA was comparably low. Over time, a decline in radiation dose was demonstrated, probably due to a combination of improvements in data acquisition protocols and patient preparation as well as installation of new CT scanners with advanced technology.
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CT angiography to evaluate coronary artery disease and revascularization requirement before trans-catheter aortic valve replacement. J Cardiovasc Comput Tomogr 2017; 11:338-346. [PMID: 28662835 DOI: 10.1016/j.jcct.2017.06.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/12/2017] [Accepted: 06/20/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) and aortic stenosis share pathophysiological mechanisms and risk factors. We evaluated the clinical utility of coronary computed tomography angiography (CTA) to identify CAD and revascularization requirement in patients with severe aortic stenosis considered for transcatheter aortic valve replacement (TAVR). METHODS Consecutive patients without known CAD underwent calcium scoring, CTA and invasive coronary angiography (ICA). A second-generation dual-source CT scanner was used. ICA-quantitative coronary angiography (QCA) served as reference standard. CAD was reported using a lenient threshold of ≥50% and a stricter threshold of ≥70% diameter reduction. Findings of ≥70% diameter reduction and of high-risk CAD were used to predict revascularization. RESULTS The study included 140 patients [68 males; 82.3 (7.7) years]. CAD defined by the 50% threshold on ICA was found in 58/140 (41%) patients. CAD by the 70% threshold was found in 23/140 (16%) patients. High-risk CAD was found in 16/140 (11%) patients. CTA and ICA had similar odd-ratios of 3.22 (1.26-8.23) and 4.62 (1.64-13.05), respectively, in predicting revascularization. Forty-two/140 (30%) patients had <400 Agatston calcium score, 98/140 (70%) patients had ≥400 calcium score. The diagnostic performance of CTA in the low calcium score group was better than the high calcium score group (AUC 0.81 vs. 0.63). CONCLUSION CTA remained questionable to rule-out CAD as gatekeeper to ICA in TAVR candidates who had severe coronary calcifications. In patients with less severe coronary calcifications, accounting for 30% of participants in this study, CTA may play a clinical role.
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Hamm K, Reents W, Zacher M, Halbfass P, Kerber S, Diegeler A, Schieffer B, Barth S. Omission of predilation in balloon-expandable transcatheter aortic valve implantation: retrospective analysis in a large-volume centre. EUROINTERVENTION 2017; 13:e161-e167. [DOI: 10.4244/eij-d-17-00011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kim WK, Liebetrau C, Renker M, Rolf A, Van Linden A, Arsalan M, Husser O, Möllmann H, Hamm C, Walther T. Transfemoral aortic valve implantation using a self-expanding transcatheter heart valve without pre-dilation. Int J Cardiol 2017; 243:156-160. [PMID: 28579166 DOI: 10.1016/j.ijcard.2017.05.092] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/12/2017] [Accepted: 05/23/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of the present study was to investigate whether transfemoral implantation of the Acurate neo transcatheter heart valve without pre-dilation is feasible. METHODS Between December 2014 and December 2016, 294 patients were treated with the Acurate neo prosthesis at our center. Of these, 72 cases were performed without pre-dilation. The decision to omit pre-dilation was at the discretion of the operator, preferably in the case of mild to moderate aortic valve calcification (AVC). Propensity matching (1:1) resulted in 48 cases in each group. Main outcomes of interest were device success according to VARC-2 criteria, residual aortic regurgitation (AR) ≥ 2°, and rate of post-dilation. RESULTS Median [IQR] age in patients without pre-dilation was 82.7 years [78.6–85.6], STS score was 4.6% [3.4–6.1], and AVC-score was 1436 AU [1043–1682] with mild and moderate AVC in 63.9% and 36.1% of cases, respectively. Device success was achieved in 94.4% of cases, post-dilation was necessary in 26.4%, and one (1.4%) patient had moderate AR. In the matched population, there were no differences regarding device success, rate of AR ≥ 2°, need for post-dilation, and post-procedural mean gradient, but the group without pre-dilation had shorter procedure (34.0 min [27.0–38.8] vs. 43.0 min [34.3–52.0]; p < 0.001) and fluoroscopy times (7.4 min [5.7–9.0] vs. 9.9 min [7.9–13.5]; p < 0.001). CONCLUSION In select patients with mild to moderate AVC, transfemoral implantation of the Acurate neo without pre-dilation is feasible and safe. This allows for a straightforward procedure that may be performed without rapid pacing in the majority of cases.
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Affiliation(s)
- Won-Keun Kim
- Kerckhoff Heart Center, Department of Cardiology, Bad Nauheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Rhein Main, Frankfurt am Main, Germany; Kerckhoff Heart Center, Department of Cardiac Surgery, Bad Nauheim, Germany; Justus-Liebig University of Giessen, Department of Cardiology, Giessen, Germany.
| | - Christoph Liebetrau
- Kerckhoff Heart Center, Department of Cardiology, Bad Nauheim, Germany; Justus-Liebig University of Giessen, Department of Cardiology, Giessen, Germany
| | - Matthias Renker
- Kerckhoff Heart Center, Department of Cardiology, Bad Nauheim, Germany
| | - Andreas Rolf
- Kerckhoff Heart Center, Department of Cardiology, Bad Nauheim, Germany; Justus-Liebig University of Giessen, Department of Cardiology, Giessen, Germany
| | - Arnaud Van Linden
- Kerckhoff Heart Center, Department of Cardiac Surgery, Bad Nauheim, Germany
| | - Mani Arsalan
- Kerckhoff Heart Center, Department of Cardiac Surgery, Bad Nauheim, Germany
| | - Oliver Husser
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Helge Möllmann
- St. Johannes Hospital, Department of Cardiology, Dortmund, Germany
| | - Christian Hamm
- Kerckhoff Heart Center, Department of Cardiology, Bad Nauheim, Germany; Justus-Liebig University of Giessen, Department of Cardiology, Giessen, Germany
| | - Thomas Walther
- Kerckhoff Heart Center, Department of Cardiac Surgery, Bad Nauheim, Germany
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Cocchia R, D’Andrea A, Conte M, Cavallaro M, Riegler L, Citro R, Sirignano C, Imbriaco M, Cappelli M, Gregorio G, Calabrò R, Bossone E. Patient selection for transcatheter aortic valve replacement: A combined clinical and multimodality imaging approach. World J Cardiol 2017; 9:212-229. [PMID: 28400918 PMCID: PMC5368671 DOI: 10.4330/wjc.v9.i3.212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/15/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has been validated as a new therapy for patients affected by severe symptomatic aortic stenosis who are not eligible for surgical intervention because of major contraindication or high operative risk. Patient selection for TAVR should be based not only on accurate assessment of aortic stenosis morphology, but also on several clinical and functional data. Multi-Imaging modalities should be preferred for assessing the anatomy and the dimensions of the aortic valve and annulus before TAVR. Ultrasounds represent the first line tool in evaluation of this patients giving detailed anatomic description of aortic valve complex and allowing estimating with enough reliability the hemodynamic entity of valvular stenosis. Angiography should be used to assess coronary involvement and plan a revascularization strategy before the implant. Multislice computed tomography play a central role as it can give anatomical details in order to choice the best fitting prosthesis, evaluate the morphology of the access path and detect other relevant comorbidities. Cardiovascular magnetic resonance and positron emission tomography are emergent modality helpful in aortic stenosis evaluation. The aim of this review is to give an overview on TAVR clinical and technical aspects essential for adequate selection.
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