What does this research mean for the field?

Routine 64- or 320-line cardiac CT scans performed before catheter ablation for atrial fibrillation can successfully evaluate coronary artery lesions in 93% of patients using the image acquisition timing optimized for left atrial-pulmonary vein anatomy, and the prevalence of myocardial ischemia in these patients correlates significantly with the CHADS2 score. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

March 5, 2020Heart and VesselsOpen Access

Evaluation of coronary artery disease in patients with atrial fibrillation by cardiac computed tomography for catheter ablation: CADAF-CT trial

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Why the study?

Ideal cardiac CT image acquisition timing differs between evaluating LA-PV anatomy for AF catheter ablation and assessing coronary artery lesions, leaving it unclear whether routine pre-ablation CT can evaluate both simultaneously.

Does routine cardiac CT before AF ablation improve the detection of coronary artery disease and myocardial ischemia in patients with atrial fibrillation?

Structured PICO

Does routine cardiac CT before AF ablation improve the detection of coronary artery disease and myocardial ischemia in patients with atrial fibrillation?

Population

606 consecutive patients with atrial fibrillation (AF) without previous histories of coronary artery disease (CAD) admitted to undergo radiofrequency catheter ablation (RFCA), mean age 69, 67% male. Excluded: renal dysfunction (serum creatinine ≥ 1.5 mg/dL) and hemodialysis.

Intervention

64- or 320-line routine cardiac computed tomography (CT) scans before RFCA of AF at the timing of image acquisition of the left atrium and pulmonary veins (LA-PVs).

Outcome

Evaluation of coronary artery lesions (CALs) and detection of myocardial ischemia (MI) in patients with severe coronary stenosis (≥50%) or unevaluable CALs.surrogate

Routine cardiac CT before AF ablation can effectively evaluate coronary artery lesions, revealing a 9% prevalence of myocardial ischemia that correlates with the CHADS2 score.

Limitations

Retrospective design
Relatively small number of patients
Patients with AF who did not undergo RFCA of AF, especially with long-lasting AF, were not included

Implication

Pre-ablation cardiac CT may aid CAD detection in AF; ischemia-CHADS2 link is hypothesis-generating and should not yet change practice.

Abstract

Almost all institutions routinely perform cardiac computed tomography (CT) before radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) to evaluate the cardiac anatomy. The ideal timing of the CT image acquisition is different between for RFCA of AF and for evaluation of coronary artery lesions (CALs). Thus, the aim of this study was to assess whether 64- or 320-line routine cardiac CT scans before RFCA of AF could evaluate both coronary artery lesions and pulmonary veins (LA-PVs) anatomy at the timing of the image acquisition of the LA-PVs in patients with AF who underwent RFCA of AF. The CALs were evaluated in 606 consecutive patients who underwent RFCA of AF assessed by the ideal timing of the CT image acquisition for RFCA of AF, and myocardial ischemia (MI) was also evaluated in patients with severe coronary stenosis (≥ 50%) and unevaluable CALs due to their severe coronary calcification and banding artifact by additional examinations combined with exercise stress testing, 201 Tl scintigraphy, and/or fractionated flow reserve measurements. This study revealed that, in patients with AF who underwent RFCA of AF, (1) both 64- and 320-line cardiac CT scans for RFCA of AF could evaluate CALs in 93% of those patients, (2) the prevalence of MI was 9%, (3) significant relationships between the CHADS 2 score and prevalence of MI were observed ( p = 0.003), and (4) the positive predict values of MI in patients with severe coronary stenosis (≥ 50%) and unevaluable CALs also significantly increased in accordance with the CHADS 2 score ( p = 0.003). The evaluation of CALs and MI by routine cardiac CT for RFCA of AF combined with the additional examinations may be one of the most feasible modalities for patients with AF.