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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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McHugh S, Allaham H, Chahal D, Gupta A. Coronary Artery Revascularization in Patients Undergoing Transcatheter Aortic Valve Replacement. Cardiol Clin 2024; 42:333-338. [PMID: 38910018 DOI: 10.1016/j.ccl.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Patients with concomitant severe aortic stenosis and significant coronary artery disease present a diagnostic and therapeutic challenge in clinical practice. There are no clear-cut guidelines as to the timing of revascularization in these patients who are referred for transcatheter aortic valve replacement (TAVR). This article aims to show that in patients without high-grade proximal coronary artery disease, revascularization after TAVR is safe, feasible, and practical. Additionally, the use of preoperative TAVR computed tomographic angiography might be used in both intermediate and high-risk patients rather than invasive coronary angiography to assess for significant proximal coronary artery disease to help guide the timing of revascularization.
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Affiliation(s)
| | | | - Diljon Chahal
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Anuj Gupta
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Pan JA, Patel AR. The Role of Multimodality Imaging in Cardiomyopathy. Curr Cardiol Rep 2024; 26:689-703. [PMID: 38753290 PMCID: PMC11236518 DOI: 10.1007/s11886-024-02068-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE OF REVIEW There has been increasing use of multimodality imaging in the evaluation of cardiomyopathies. RECENT FINDINGS Echocardiography, cardiac magnetic resonance (CMR), cardiac nuclear imaging, and cardiac computed tomography (CCT) play an important role in the diagnosis, risk stratification, and management of patients with cardiomyopathies. Echocardiography is essential in the initial assessment of suspected cardiomyopathy, but a multimodality approach can improve diagnostics and management. CMR allows for accurate measurement of volumes and function, and can easily detect unique pathologic structures. In addition, contrast imaging and parametric mapping enable the characterization of tissue features such as scar, edema, infiltration, and deposition. In non-ischemic cardiomyopathies, metabolic and molecular nuclear imaging is used to diagnose rare but life-threatening conditions such amyloidosis and sarcoidosis. There is an expanding use of CCT for planning electrophysiology procedures such as cardioversion, ablations, and device placement. Furthermore, CCT can evaluate for complications associated with advanced heart failure therapies such as cardiac transplant and mechanical support devices. Innovations in multimodality cardiac imaging should lead to increased volumes and better outcomes.
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Affiliation(s)
- Jonathan A Pan
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, 1215 Lee Street, Box 800158, Charlottesville, VA, 22908, USA
| | - Amit R Patel
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, 1215 Lee Street, Box 800158, Charlottesville, VA, 22908, USA.
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Harik L, Gaudino M. Coronary angiography and bypass surgery: born together and now going separate ways? Eur Heart J 2024; 45:1816-1818. [PMID: 38583087 DOI: 10.1093/eurheartj/ehae223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/08/2024] Open
Affiliation(s)
- Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065, USA
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5
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Steyer A, Puntmann VO, Nagel E, Leistner DM, Koch V, Vasa-Nicotera M, Kumar P, Booz C, Vogl TJ, Mas-Peiro S, Martin SS. Coronary Artery Disease Assessment via On-Site CT Fractional Flow Reserve in Patients Undergoing Transcatheter Aortic Valve Replacement. Radiol Cardiothorac Imaging 2024; 6:e230096. [PMID: 38546330 PMCID: PMC11056750 DOI: 10.1148/ryct.230096] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 01/05/2024] [Accepted: 02/14/2024] [Indexed: 05/01/2024]
Abstract
Purpose To examine the clinical feasibility of workstation-based CT fractional flow reserve (CT-FFR) for coronary artery disease (CAD) evaluation during preprocedural planning in patients undergoing transcatheter aortic valve replacement (TAVR). Materials and Methods In this retrospective single-center study, 434 patients scheduled for TAVR between 2018 and 2020 were screened for study inclusion; a relevant proportion of patients (35.0% [152 of 434]) was not suitable for evaluation due to insufficient imaging properties. A total of 112 patients (mean age, 82.1 years ± 6.7 [SD]; 58 [52%] men) were included in the study. Invasive angiography findings, coronary CT angiography results, and Agatston score were acquired and compared with on-site CT-FFR computation for evaluation of CAD and prediction of major adverse cardiovascular events (MACE) within a 24-month follow-up. Results Hemodynamic relevant CAD, as suggested by CT-FFR of 0.80 or less, was found in 41 of 70 (59%) patients with stenosis of 50% or more. MACE occurred in 23 of 112 (20.5%) patients, from which 14 of 23 had stenoses with CT-FFR of 0.80 or less (hazard ratio [HR], 3.33; 95% CI: 1.56, 7.10; P = .002). CT-FFR remained a significant predictor of MACE after inclusion in a multivariable model with relevant covariables (HR, 2.89; 95% CI: 1.22, 6.86; P = .02). An Agatston score of 1000 Agatston units or more (HR, 2.25; 95% CI: 0.98, 5.21; P = .06) and stenoses of 50% or more determined via invasive angiography (HR, 0.94; 95% CI: 0.41, 2.17; P = .88) were not significant predictors of MACE. Conclusion Compared with conventional CAD markers, CT-FFR better predicted adverse outcomes after TAVR. A relevant portion of the screened cohort, however, was not suitable for CT-based CAD evaluation. Keywords: CT, Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR), Cardiac, Coronary Arteries, Outcomes Analysis © RSNA, 2024 See also the commentary by Weir-McCall and Pugliese in this issue.
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Affiliation(s)
- Alexandra Steyer
- From the Department of Diagnostic and Interventional Radiology (A.S.,
V.K., C.B., T.J.V., S.S.M.), Institute for Experimental and Translational
Cardiovascular Imaging (A.S., V.O.P., E.N., P.K., S.S.M.), and Department of
Cardiology (D.M.L., M.V.N., S.M.P.), Goethe University Frankfurt, University
Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; Department of
Radiology, Fortis Escort Heart Institute, New Delhi, India (P.K.); German Centre
for Cardiovascular Research, Berlin, Germany (E.N., M.V.N., S.M.P., S.S.M.); and
Cardiopulmonary Institute, Frankfurt, Germany (S.M.P.)
| | - Valentina O. Puntmann
- From the Department of Diagnostic and Interventional Radiology (A.S.,
V.K., C.B., T.J.V., S.S.M.), Institute for Experimental and Translational
Cardiovascular Imaging (A.S., V.O.P., E.N., P.K., S.S.M.), and Department of
Cardiology (D.M.L., M.V.N., S.M.P.), Goethe University Frankfurt, University
Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; Department of
Radiology, Fortis Escort Heart Institute, New Delhi, India (P.K.); German Centre
for Cardiovascular Research, Berlin, Germany (E.N., M.V.N., S.M.P., S.S.M.); and
Cardiopulmonary Institute, Frankfurt, Germany (S.M.P.)
| | - Eike Nagel
- From the Department of Diagnostic and Interventional Radiology (A.S.,
V.K., C.B., T.J.V., S.S.M.), Institute for Experimental and Translational
Cardiovascular Imaging (A.S., V.O.P., E.N., P.K., S.S.M.), and Department of
Cardiology (D.M.L., M.V.N., S.M.P.), Goethe University Frankfurt, University
Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; Department of
Radiology, Fortis Escort Heart Institute, New Delhi, India (P.K.); German Centre
for Cardiovascular Research, Berlin, Germany (E.N., M.V.N., S.M.P., S.S.M.); and
Cardiopulmonary Institute, Frankfurt, Germany (S.M.P.)
| | - David M. Leistner
- From the Department of Diagnostic and Interventional Radiology (A.S.,
V.K., C.B., T.J.V., S.S.M.), Institute for Experimental and Translational
Cardiovascular Imaging (A.S., V.O.P., E.N., P.K., S.S.M.), and Department of
Cardiology (D.M.L., M.V.N., S.M.P.), Goethe University Frankfurt, University
Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; Department of
Radiology, Fortis Escort Heart Institute, New Delhi, India (P.K.); German Centre
for Cardiovascular Research, Berlin, Germany (E.N., M.V.N., S.M.P., S.S.M.); and
Cardiopulmonary Institute, Frankfurt, Germany (S.M.P.)
| | - Vitali Koch
- From the Department of Diagnostic and Interventional Radiology (A.S.,
V.K., C.B., T.J.V., S.S.M.), Institute for Experimental and Translational
Cardiovascular Imaging (A.S., V.O.P., E.N., P.K., S.S.M.), and Department of
Cardiology (D.M.L., M.V.N., S.M.P.), Goethe University Frankfurt, University
Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; Department of
Radiology, Fortis Escort Heart Institute, New Delhi, India (P.K.); German Centre
for Cardiovascular Research, Berlin, Germany (E.N., M.V.N., S.M.P., S.S.M.); and
Cardiopulmonary Institute, Frankfurt, Germany (S.M.P.)
| | - Mariuca Vasa-Nicotera
- From the Department of Diagnostic and Interventional Radiology (A.S.,
V.K., C.B., T.J.V., S.S.M.), Institute for Experimental and Translational
Cardiovascular Imaging (A.S., V.O.P., E.N., P.K., S.S.M.), and Department of
Cardiology (D.M.L., M.V.N., S.M.P.), Goethe University Frankfurt, University
Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; Department of
Radiology, Fortis Escort Heart Institute, New Delhi, India (P.K.); German Centre
for Cardiovascular Research, Berlin, Germany (E.N., M.V.N., S.M.P., S.S.M.); and
Cardiopulmonary Institute, Frankfurt, Germany (S.M.P.)
| | - Parveen Kumar
- From the Department of Diagnostic and Interventional Radiology (A.S.,
V.K., C.B., T.J.V., S.S.M.), Institute for Experimental and Translational
Cardiovascular Imaging (A.S., V.O.P., E.N., P.K., S.S.M.), and Department of
Cardiology (D.M.L., M.V.N., S.M.P.), Goethe University Frankfurt, University
Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; Department of
Radiology, Fortis Escort Heart Institute, New Delhi, India (P.K.); German Centre
for Cardiovascular Research, Berlin, Germany (E.N., M.V.N., S.M.P., S.S.M.); and
Cardiopulmonary Institute, Frankfurt, Germany (S.M.P.)
| | - Christian Booz
- From the Department of Diagnostic and Interventional Radiology (A.S.,
V.K., C.B., T.J.V., S.S.M.), Institute for Experimental and Translational
Cardiovascular Imaging (A.S., V.O.P., E.N., P.K., S.S.M.), and Department of
Cardiology (D.M.L., M.V.N., S.M.P.), Goethe University Frankfurt, University
Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; Department of
Radiology, Fortis Escort Heart Institute, New Delhi, India (P.K.); German Centre
for Cardiovascular Research, Berlin, Germany (E.N., M.V.N., S.M.P., S.S.M.); and
Cardiopulmonary Institute, Frankfurt, Germany (S.M.P.)
| | - Thomas J. Vogl
- From the Department of Diagnostic and Interventional Radiology (A.S.,
V.K., C.B., T.J.V., S.S.M.), Institute for Experimental and Translational
Cardiovascular Imaging (A.S., V.O.P., E.N., P.K., S.S.M.), and Department of
Cardiology (D.M.L., M.V.N., S.M.P.), Goethe University Frankfurt, University
Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; Department of
Radiology, Fortis Escort Heart Institute, New Delhi, India (P.K.); German Centre
for Cardiovascular Research, Berlin, Germany (E.N., M.V.N., S.M.P., S.S.M.); and
Cardiopulmonary Institute, Frankfurt, Germany (S.M.P.)
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Dai N, Tang X, Ling R, Zhou F, Chen S, Zhang L, Duan S, Pan W, Zhang J, Zhou D, Ge J. Prognostic implications of pre-transcatheter aortic valve replacement computed tomography-derived coronary plaque characteristics and stenosis severity. Eur Radiol 2024:10.1007/s00330-024-10633-7. [PMID: 38308681 DOI: 10.1007/s00330-024-10633-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/27/2023] [Accepted: 12/08/2023] [Indexed: 02/05/2024]
Abstract
OBJECTIVES The study aimed to investigate the prognostic value of pre-transcatheter aortic valve replacement (TAVR) computed tomography angiography (CTA) in assessing physiological stenosis severity (CTA-derived fractional flow reserve (CT-FFR)) and high-risk plaque characteristics (HRPC). MATERIALS AND METHODS Among TAVR patients who underwent pre-procedure CTA, the presence and number of HRPCs (minimum lumen area of < 4 mm2, plaque burden ≥ 70%, low-attenuating plaques, positive remodeling, napkin-ring sign, or spotty calcification) as well as CT-FFR were assessed. The risk of vessel-oriented composite outcome (VOCO, a composite of vessel-related ischemia-driven revascularization, vessel-related myocardial infarction, or cardiac death) was compared according to the number of HRPC and CT-FFR categories. RESULTS Four hundred and twenty-seven patients (68.4% were male) with 1072 vessels were included. Their mean age was 70.6 ± 10.6 years. Vessels with low CT-FFR (≤ 0.80) (41.7% vs. 15.8%, adjusted hazard ratio (HRadj) 1.96; 95% confidence interval (CI): 1.28-2.96; p = 0.001) or lesions with ≥ 3 HRPC (38.7% vs. 16.0%, HRadj 1.81; 95%CI 1.20-2.71; p = 0.005) demonstrated higher VOCO risk. In the CT-FFR (> 0.80) group, lesions with ≥ 3 HRPC showed a significantly higher risk of VOCO than those with < 3 HRPC (34.7% vs. 13.0%; HRadj 2.04; 95%CI 1.18-3.52; p = 0.011). However, this relative increase in risk was not observed in vessels with positive CT-FFR (≤ 0.80). CONCLUSIONS In TAVR candidates, both CT-FFR and the presence of ≥ 3 HRPC were associated with an increased risk of adverse clinical events. However, the value of HRPC differed with the CT-FFR category, with more incremental predictability among vessels with negative CT-FFR but not among vessels with positive CT-FFR. CLINICAL RELEVANCE STATEMENT In transcatheter aortic valve replacement (TAVR) candidates, pre-TAVR CTA provided the opportunity to assess coronary physiological stenosis severity and high-risk plaque characteristics, both of which are associated with worse clinical outcomes. KEY POINTS • The current study investigated the prognostic value of coronary physiology significance and plaque characteristics in transcatheter aortic valve replacement patients. • The combination of coronary plaque vulnerability and physiological significance showed improved accuracy in predicting clinical outcomes in transcatheter aortic valve replacement patients. • Pre-transcatheter aortic valve replacement CT can be a one-stop-shop tool for coronary assessments in clinical practice.
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Affiliation(s)
- Neng Dai
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Xianglin Tang
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Runjianya Ling
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Fan Zhou
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Shasha Chen
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Lei Zhang
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | | | - Wenzhi Pan
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Jiayin Zhang
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, #85 Wujin Rd, Shanghai, 200080, China.
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China.
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China.
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China.
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China.
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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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Gohmann RF, Schug A, Pawelka K, Seitz P, Majunke N, El Hadi H, Heiser L, Renatus K, Desch S, Leontyev S, Noack T, Kiefer P, Krieghoff C, Lücke C, Ebel S, Borger MA, Thiele H, Panknin C, Abdel-Wahab M, Horn M, Gutberlet M. Interrater variability of ML-based CT-FFR during TAVR-planning: influence of image quality and coronary artery calcifications. Front Cardiovasc Med 2023; 10:1301619. [PMID: 38188259 PMCID: PMC10768187 DOI: 10.3389/fcvm.2023.1301619] [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: 09/25/2023] [Accepted: 11/13/2023] [Indexed: 01/09/2024] Open
Abstract
Objective To compare machine learning (ML)-based CT-derived fractional flow reserve (CT-FFR) in patients before transcatheter aortic valve replacement (TAVR) by observers with differing training and to assess influencing factors. Background Coronary computed tomography angiography (cCTA) can effectively exclude CAD, e.g. prior to TAVR, but remains limited by its specificity. CT-FFR may mitigate this limitation also in patients prior to TAVR. While a high reliability of CT-FFR is presumed, little is known about the reproducibility of ML-based CT-FFR. Methods Consecutive patients with obstructive CAD on cCTA were evaluated with ML-based CT-FFR by two observers. Categorization into hemodynamically significant CAD was compared against invasive coronary angiography. The influence of image quality and coronary artery calcium score (CAC) was examined. Results CT-FFR was successfully performed on 214/272 examinations by both observers. The median difference of CT-FFR between both observers was -0.05(-0.12-0.02) (p < 0.001). Differences showed an inverse correlation to the absolute CT-FFR values. Categorization into CAD was different in 37/214 examinations, resulting in net recategorization of Δ13 (13/214) examinations and a difference in accuracy of Δ6.1%. On patient level, correlation of absolute and categorized values was substantial (0.567 and 0.570, p < 0.001). Categorization into CAD showed no correlation to image quality or CAC (p > 0.13). Conclusion Differences between CT-FFR values increased in values below the cut-off, having little clinical impact. Categorization into CAD differed in several patients, but ultimately only had a moderate influence on diagnostic accuracy. This was independent of image quality or CAC.
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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
| | - Adrian Schug
- 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, University of Leipzig, Leipzig, Germany
| | - Hamza El Hadi
- Department of Cardiology, Heart Center Leipzig, 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, University of Leipzig, Leipzig, Germany
| | - Sergey Leontyev
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Thilo Noack
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Philipp Kiefer
- Department of Cardiac Surgery, Heart Center Leipzig, University of 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, University of Leipzig, Leipzig, Germany
- Helios Health Institute, Leipzig, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
- Helios Health Institute, Leipzig, Germany
| | | | - Mohamed Abdel-Wahab
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Matthias Horn
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), 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
- Helios Health Institute, Leipzig, Germany
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9
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Radunović A, Vidaković R, Timčić S, Odanović N, Stefanović M, Lipovac M, Krupniković K, Mandić A, Kojić D, Tomović M, Ilić I. Multislice computerized tomography coronary angiography can be a comparable tool to intravascular ultrasound in evaluating "true" coronary artery bifurcations. Front Cardiovasc Med 2023; 10:1292517. [PMID: 38028491 PMCID: PMC10657987 DOI: 10.3389/fcvm.2023.1292517] [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: 09/11/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Aim Coronary bifurcation atherosclerosis depends on its angles, flow, and extensive branching. We investigate the ability of CT coronary angiography (CTCA) to determine atherosclerotic plaque characteristics of "true" bifurcation compared with intravascular ultrasound (IVUS) and the influence on side branch (SB) fate after percutaneous coronary intervention (PCI). Methods and results The study included 70 patients with 72 "true" bifurcations. Most of the bifurcations were in the left anterior descending-diagonal (Dg) territory [50 out of 72 (69.4%)]. Longitudinal plaque evaluation at the polygon of confluence [carina and 5 mm proximal and distal in the main branch (MB)] showed that carina side MB and SB plaque had occurred with the lowest incidence with fibro-lipid structure (115 ± 63 HU and 89 ± 73 HU, p < 0.001 for all). Bland-Altman analysis showed a discrepancy in measuring mainly the lumen area between CTCA and IVUS in proximal MB [lumen 5.10, 95% CI (95% confidence interval, 4.53-5.68) mm2, p < 0.001; vessel -1.42, 95% CI (-2.63 to -0.21) mm2, p = 0.023], carina MB [lumen 3.74, 95% CI (3.37-4.10) mm2, p < 0.001; vessel -0.48, 95% CI (-1.45 to 0.48) mm2, p = 0.322], and distal MB [lumen 4.72, 95% CI (4.27-5.18) mm2, p < 0.001; vessel 0.62, 95% CI (-0.53 to 1.77) mm2, p = 0.283]. A significant correlation existed between average plaque density on CTCA with a percentage of calcified plaque on IVUS tissue characterization (proximal r = 0.307/p = 0.024, carina 0.469/0.008, distal 0.339/0.024, minimal lumen diameter 0.318/0.020). Circumferential plaque in the proximal MB segment remained an independent predictor of SB compromise [OR 3.962 (95% CI 1.170-13.418)]. Conclusion Detection and characterization of atherosclerotic plaque by CTCA in non-left main "true" coronary bifurcations can provide useful information about bifurcation anatomy and plaque distribution that can predict outcomes after provisional stenting, thus guiding the interventional strategy to bifurcation PCI.
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Affiliation(s)
- Anja Radunović
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Radosav Vidaković
- Department of Cardiology, Clinical Hospital Center Zemun, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Stefan Timčić
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Natalija Odanović
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Milica Stefanović
- Department of Cardiology, Clinical Hospital Center Zemun, Belgrade, Serbia
| | - Mirko Lipovac
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Kosta Krupniković
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Aleksandar Mandić
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Dejan Kojić
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Milosav Tomović
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Ivan Ilić
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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10
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Zhang Y, Liu P, Tang LJ, Lin PM, Li R, Luo HR, Luo P. Basing on the machine learning model to analyse the coronary calcification score and the coronary flow reserve score to evaluate the degree of coronary artery stenosis. Comput Biol Med 2023; 163:107130. [PMID: 37329614 DOI: 10.1016/j.compbiomed.2023.107130] [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: 03/19/2023] [Revised: 05/23/2023] [Accepted: 06/01/2023] [Indexed: 06/19/2023]
Abstract
AIM To obtain the coronary artery calcium score (CACS) for each branch in coronary artery computed tomography angiography (CCTA) examination combined with the flow fraction reserve (FFR) of each branch in the coronary artery detected by CT and apply a machine learning model (ML) to analyse and predict the severity of coronary artery stenosis. METHODS All patients who underwent coronary computed tomography angiography (CCTA) from January 2019 to April 2022 in the HOSPITAL (T.C.M) AFFILIATED TO SOUTHWEST MEDICAL UNIVERSITY) were retrospectively screened, and their sex, age, characteristics of lipid-containing lesions, coronary calcium score (CACS) and CT-FFR values were collected. Five machine learning models, random forest (RF), k-nearest neighbour algorithm (KNN), kernel logistic regression, support vector machine (SVM) and radial basis function neural network (RBFNN), were used as predictive models to evaluate the severity of coronary stenosis. RESULTS Among the five machine learning models, the SVM model achieved the best prediction performance, and the prediction accuracy of mild stenosis was up to 90%. Second, age and male sex were important influencing factors of increasing CACS and decreasing CT-FFR. Moreover, the critical CACS value of myocardial ischemia >200.70 was calculated. CONCLUSION Through computer machine learning model analysis, we prove the importance of CACS and FFR in predicting coronary stenosis, especially the prominent vector machine model, which promotes the application of artificial intelligence computer learning methods in the field of medical analysis.
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Affiliation(s)
- Ying Zhang
- State Key Laboratories for Quality Research in Chinese Medicines, Faculty of Pharmacy, Macau University of Science and Technology, Macau; Department of Anaesthesiology, HOSPITAL (T.C.M) AFFILIATED TO SOUTHWEST MEDICAL UNIVERSITY), Lu Zhou, (646000), Sichuan, China.
| | - Ping Liu
- Department of Anaesthesiology, HOSPITAL (T.C.M) AFFILIATED TO SOUTHWEST MEDICAL UNIVERSITY), Lu Zhou, (646000), Sichuan, China.
| | - Li-Jia Tang
- Department of Anaesthesiology, HOSPITAL (T.C.M) AFFILIATED TO SOUTHWEST MEDICAL UNIVERSITY), Lu Zhou, (646000), Sichuan, China.
| | - Pei-Min Lin
- Department of Anaesthesiology, HOSPITAL (T.C.M) AFFILIATED TO SOUTHWEST MEDICAL UNIVERSITY), Lu Zhou, (646000), Sichuan, China.
| | - Run Li
- Department of Anaesthesiology, HOSPITAL (T.C.M) AFFILIATED TO SOUTHWEST MEDICAL UNIVERSITY), Lu Zhou, (646000), Sichuan, China.
| | - Huai-Rong Luo
- State Key Laboratories for Quality Research in Chinese Medicines, Faculty of Pharmacy, Macau University of Science and Technology, Macau.
| | - Pei Luo
- State Key Laboratories for Quality Research in Chinese Medicines, Faculty of Pharmacy, Macau University of Science and Technology, Macau.
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11
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Kondoleon NP, Layoun H, Spilias N, Sipko J, Kanaan C, Harb S, Reed G, Puri R, Yun J, Krishnaswamy A, Kapadia SR. Effectiveness of Pre-TAVR CTA as a Screening Tool for Significant CAD Before TAVR. JACC Cardiovasc Interv 2023; 16:1990-2000. [PMID: 37648347 DOI: 10.1016/j.jcin.2023.05.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/10/2023] [Accepted: 05/16/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Computed tomography angiography (CTA) and invasive coronary angiography (ICA) are routinely performed before transcatheter aortic valve replacement (TAVR) to assess aortic root anatomy and screen for coronary artery disease (CAD), respectively. OBJECTIVES This study explored the efficacy of CTA as a screening tool for significant proximal CAD before TAVR. METHODS With proper ethical oversight, patients undergoing TAVR at Cleveland Clinic with a preprocedural CTA and invasive coronary angiography (ICA), and no prior percutaneous intervention, were identified from 2015 to 2021. Blinded to ICA results, the authors reviewed the left main, proximal left anterior descending coronary artery, proximal left circumflex coronary artery, and proximal right coronary artery by CTA coronary reconstruction to assess for nonsignificant stenosis (0% to 49%), moderate stenosis (50% to 69%), and severe stenosis (≥70%). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Cohen Kappa statistic were analyzed. RESULTS 2,217 patients (53.4% male, age 79.2 ± 8.5 years) met inclusion criteria. CTA evaluation revealed a sensitivity of 90%, specificity of 92%, PPV of 74%, and NPV of 97% for detecting ≥50% stenosis. Using a ≥70% stenosis cutoff, evaluation revealed a sensitivity of 91%, specificity of 97%, PPV of 83%, and NPV of 99%. Assessment of bypass graft patency revealed a sensitivity of 86%, specificity of 97%, PPV of 84%, and NPV of 98%. Cohen Kappa analysis indicated substantial to near perfect agreement between pre-TAVR CTA and ICA. CONCLUSIONS Pre-TAVR CTA has a high NPV for high-grade proximal stenosis of each coronary artery. As a result, CTA can be used as a screening tool to rule out significant proximal CAD in patients undergoing TAVR.
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Affiliation(s)
- Nicholas P Kondoleon
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA. https://twitter.com/npkondo
| | - Habib Layoun
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nikolaos Spilias
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Joseph Sipko
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Christopher Kanaan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Serge Harb
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Grant Reed
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - James Yun
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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12
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Garot P. A Minute of Silence for ICA Before TAVR?: Some More Work Is Needed. JACC Cardiovasc Interv 2023; 16:2001-2003. [PMID: 37648348 DOI: 10.1016/j.jcin.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Philippe Garot
- Institut Cardiovasculaire Paris-Sud (ICPS), Hôpital Privé Jacques Cartier, Ramsay-Santé, Massy, France.
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13
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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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14
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Gama FF, Patel K, Bennett J, Aziminia N, Pugliese F, Treibel T. Myocardial Evaluation in Patients with Aortic Stenosis by Cardiac Computed Tomography. ROFO-FORTSCHR RONTG 2023; 195:506-513. [PMID: 36854383 DOI: 10.1055/a-1999-7271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Aortic valve stenosis (AVS) is one of the most prevalent pathologies affecting the heart that can curtail expected survival and quality of life if not managed appropriately. CURRENT STATUS Cardiac computed tomography (CT) has long played a central role in this subset, mostly for severity assessment and for procedural planning. Although not as widely accepted as other imaging modalities for functional myocardial assessment [i. e., transthoracic echocardiogram (TTE), cardiac magnetic resonance (CMR)], this technique has recently increased its clinical application in this regard. FUTURE OUTLOOK The ability to provide morphological, functional, tissue, and preprocedural information highlights the potential of the "all-in-one" concept of cardiac CT as a potential reality for the near future for AVS assessment. In this review article, we sought to analyze the current applications of cardiac CT that allow a full comprehensive evaluation of aortic valve disease. KEY POINTS · Noninvasive myocardial tissue characterization stopped being an exclusive feature of cardiac magnetic resonance.. · Emerging acquisition methods make cardiac CT an accurate and widely accessible imaging modality.. · Cardiac CT has the potential to become a "one-stop" exam for comprehensive aortic stenosis assessment.. CITATION FORMAT · Gama FF, Patel K, Bennett J et al. Myocardial Evaluation in Patients with Aortic Stenosis by Cardiac Computed Tomography. Fortschr Röntgenstr 2023; DOI: 10.1055/a-1999-7271.
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Affiliation(s)
- Francisco F Gama
- Cardiology, Hospital Centre of West Lisbon Campus Hospital of Santa Cruz, Lisboa, Portugal.,Cardiac Imaging, Barts Health NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Kush Patel
- Cardiac Imaging, Barts Health NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Jonathan Bennett
- Cardiac Imaging, Barts Health NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Nikoo Aziminia
- Cardiac Imaging, Barts Health NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Francesca Pugliese
- Cardiac Imaging, Barts Health NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Thomas Treibel
- Cardiac Imaging, Barts Health NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
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15
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Tipograf Y, McLaren T, Savoie B, Kumar A, Levack MM. The role of coronary CTA and CT-fractional flow reserve evaluating coronary artery disease in transcatheter aortic valve replacement. J Card Surg 2022; 37:4133-4137. [PMID: 36183383 DOI: 10.1111/jocs.16967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 09/14/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Yuliya Tipograf
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thomas McLaren
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brent Savoie
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anupam Kumar
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Melissa M Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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16
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Guedeney P, Collet JP. [How to select the best device using pre-TAVR CT scan]. Ann Cardiol Angeiol (Paris) 2022; 71:407-412. [PMID: 36273953 DOI: 10.1016/j.ancard.2022.10.001] [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: 09/18/2022] [Revised: 09/23/2022] [Accepted: 10/03/2022] [Indexed: 06/16/2023]
Abstract
Transcatheter aortic valve replacement or TAVR has become the gold standard for the treatment of symptomatic and severe aortic valve stenosis in elderly patients. Although the role of computed tomography imaging was initially limited to the determination of the optimal vascular approach, it has progressively matured to become the pilar of TAVR work-up while being standardized by consensus conferences. The list of evaluated elements includes aortic annulus diameter, the optimal projection curve, the number of aortic leaflets, the severity and localization of calcifications, coronary ostial height, membranous septum length and aortic angulation. The proper and cautious evaluation of these elements may help evaluating the risk for the main periprocedural complications such as coronary obstruction, annular rupture, permanent pacemaker implantation or procedural failure and selecting the optimal transcatheter heart valve and its size, according to the patient's specific anatomy. In this review, we detail how the evaluation of these parameters may impact the selection of the transcatheter heart valve.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION study group, UMR_S 1166, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), 47 boulevard de l'hôpital, 75013, Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION study group, UMR_S 1166, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), 47 boulevard de l'hôpital, 75013, Paris, France.
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17
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Current Concepts and Future Applications of Non-Invasive Functional and Anatomical Evaluation of Coronary Artery Disease. Life (Basel) 2022; 12:life12111803. [PMID: 36362957 PMCID: PMC9696378 DOI: 10.3390/life12111803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
Over the last decades, significant advances have been achieved in the treatment of coronary artery disease (CAD). Proper non-invasive diagnosis and appropriate management based on functional information and the extension of ischemia or viability remain the cornerstone in the fight against adverse CAD events. Stress echocardiography and single photon emission computed tomography are often used for the evaluation of ischemia. Advancements in non-invasive imaging modalities such as computed tomography (CT) coronary angiography and cardiac magnetic resonance imaging (MRI) have not only allowed non-invasive imaging of coronary artery lumen but also provide additional functional information. Other characteristics regarding the plaque morphology can be further evaluated with the latest modalities achieving a morpho-functional evaluation of CAD. Advances in the utilization of positron emission tomography (PET), as well as software advancements especially regarding cardiac CT, may provide additional prognostic information to a more evidence-based treatment decision. Since the armamentarium on non-invasive imaging modalities has evolved, the knowledge of the capabilities and limitations of each imaging modality should be evaluated in a case-by-case basis to achieve the best diagnosis and treatment decision. In this review article, we present the most recent advances in the noninvasive anatomical and functional evaluation of CAD.
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18
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CT-FFR in the TAVR Work-Up: Optimizing the Gatekeeper. JACC Cardiovasc Interv 2022; 15:1150-1152. [PMID: 35568643 DOI: 10.1016/j.jcin.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 11/20/2022]
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