Diagnostic Performance of Angiography-Derived Coronary Physiology in Transcatheter Aortic Valve Implantation Pathway: A Systematic Review and Diagnostic Accuracy Meta-Analysis

OBJECTIVES: Coronary artery disease affects nearly half of patients undergoing transcatheter aortic valve implantation (TAVI), but the accuracy of angiography-derived, wire-free coronary physiology in severe aortic stenosis remains uncertain. The authors evaluated its diagnostic performance for detecting fractional flow reserve (FFR)-defined significant stenoses in TAVI candidates and assessed whether accuracy differed when invasive FFR was measured before vs after TAVI. METHODS: A diagnostic accuracy meta-analysis was performed including studies reporting lesion-level comparisons between angiography-derived physiology (threshold ≤0.80) and invasive FFR (≤0.80) in patients undergoing TAVI evaluation. All included studies evaluated quantitative flow ratio (QFR) or Murray-law-based QFR; no eligible studies using FFRangio or vFFR were identified. Pooled sensitivity and specificity were calculated using random-effects models. Diagnostic odds ratios (DOR), likelihood ratios, and post-test probabilities were derived. Meta-regression evaluated the impact of FFR timing (CRD420261332222). RESULTS: Five studies met inclusion criteria. Four studies (422 lesions) contributed to the primary analysis and 3 studies (250 lesions) to the secondary analysis. In the primary analysis, pooled sensitivity was 0.79 (95% CI, 0.68-0.87) and specificity 0.88 (95% CI, 0.80-0.93) (DOR 28). In the secondary analysis, sensitivity was 0.71 (95% CI, 0.57-0.82) and specificity 0.95 (95% CI, 0.90-0.98) (DOR 46.5), with comparable global discrimination (Youden index 0.66 vs 0.67). Meta-regression showed no significant interaction by reference timing (P = .39). CONCLUSIONS: Angiography-derived coronary physiology demonstrates good diagnostic performance in patients undergoing TAVI evaluation, with comparable overall discrimination when referenced to both pre- and post-TAVI FFR, although interpretation is limited by the absence of a stable reference standard across hemodynamic states.