Value of coronary CT angiography in ruling out obstructive coronary artery disease in high-risk patients candidates for TAVI

Background Coronary computed tomography angiography (CTA) is currently considered a reliable method to rule out obstructive coronary artery disease (O-CAD) before valvular heart surgery in patients with low to intermediate pre-test probability. However, its role in excluding O-CAD in high-risk patients before transcatheter aortic valve implantation (TAVI) is less well established. Our aim is to assess the value of coronary CTA in safely and effectively ruling out O-CAD in high-risk patients undergoing TAVI in a tertiary care center. Methods We conducted a single-center, retrospective study, enrolling patients with severe symptomatic aortic stenosis indicated for TAVI, who underwent coronary CTA and subsequent invasive coronary angiography (ICA) before valvular heart replacement. O-CAD was defined as a ≥ 50% stenosis in an epicardial vessel ≥ 2 mm diameter, in both coronary CTA and ICA. Patients were divided into two groups: those with a CTA scan negative for O-CAD, in whom invasive ICA was omitted, and those with a positive or inconclusive CTA scan, who underwent ICA. PCI was performed in those suitable for revascularization. A 12-month clinical follow-up was carried out in all patients. Results Our registry included 163 patients, 31 of whom did not undergo coronary CTA for clinical reasons. Thus, 132 patients (63% female; mean age 84.1 ± 4.9 years) underwent coronary CTA, with 85 patients (64.4%) having negative results for O-CAD. Among those with positive coronary CTA (n=21 [15.9%]), O-CAD was confirmed by ICA in 81.0% (n=17), with over half undergoing PCI (n=11; 52.4%). In patients with inconclusive coronary CTA (n=26 [19.7%]), O-CAD was confirmed in 61.5% (n=16), with 52.4% (n=11) undergoing PCI. The mean time interval from CTA to ICA was 32.8 ± 42.9 days. At 12 months, no statistically significant differences in periprocedural complications, cardiovascular events, or mortality were observed between the two groups. The incidence of myocardial infarction was 1.2% (n=1) and 4.3% (n=2) in patients with no evidence of O-CAD at coronary CTA and those with a positive or inconclusive scan, respectively (p = 0.2885). Conclusions Pre-procedural coronary CTA may be safe and effective in ruling out O-CAD in a significant proportion of eligible high-risk patients undergoing TAVI. The results suggest that performing an ICA is unnecessary, avoiding the need for additional contrast medium, with no occurrence of unexpected cardiovascular events during the 12-month follow-up. However, the added value of coronary CTA scan in ruling in patients with O-CAD is uncertain and remains to be clarified.