Noncoronary Gated Transcatheter Aortic Valve Replacement Computed Tomography Scans Can Safely Replace Invasive Coronary Angiography Pre-Transcatheter Aortic Valve Replacement

Patients with severe aortic stenosis often have concomitant coronary artery disease (CAD), detectable in up to 65% of cases.1Shamekhi J. Stundl A. Weber M. et al.Impact of coronary artery disease in patients undergoing transfemoral transcatheter aortic valve implantation.Int J Cardiol. 2017; 245: 215-221https://doi.org/10.1016/J.IJCARD.2017.07.082Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Concomitant CAD may increase adverse coronary events during transcatheter aortic valve replacement (TAVR) and, in the absence of a robust evidence base, may promote consideration of percutaneous coronary intervention (PCI) pre-TAVR.2D’Ascenzo F. Verardi R. Visconti M. et al.Independent impact of extent of coronary artery disease and percutaneous revascularisation on 30-day and one-year mortality after TAVI: a meta-analysis of adjusted observational results.EuroIntervention. 2018; 14: E1169-E1177https://doi.org/10.4244/EIJ-D-18-00098Crossref PubMed Scopus (63) Google Scholar Although practice is evolving, due to a lack of safety data, many Valve Teams still mandate invasive coronary angiography (ICA) as a prerequisite for patients being considered for TAVR.3Faroux L. Guimaraes L. Wintzer-Wehekind J. et al.Coronary artery disease and transcatheter aortic valve replacement: JACC state-of-the-art review.J Am Coll Cardiol. 2019; 74: 362-372https://doi.org/10.1016/J.JACC.2019.06.012Crossref PubMed Scopus (0) Google Scholar TAVR planning includes a noncoronary gated TAVR computed tomography (CT) scan (TAVRCT) (i.e., retrospective-gated protocol of the aortic root followed by a nongated CT of the whole aorta) in all patients. Therefore, the TAVRCT is different to the dedicated assessment of coronary anatomy achieved with a CT coronary angiogram. In severe aortic stenosis patients, complete anatomical assessment of the coronary circulation on a noncoronary gated TAVRCT is often precluded by excessive coronary calcification ± limited coronary opacification. However, detailed anatomical assessment of the proximal coronary circulation may still be feasible. In this study, we aimed to determine the diagnostic performance of noncoronary gated TAVRCT scans to identify anatomically significant proximal CAD (CADp) assessed against i) ICA as the reference standard, ii) peri-TAVR adverse coronary events (defined as either coronary obstruction and/or the need for emergency bail-out PCI), and iii) alteration in the pre-TAVR planning pathway (defined as the Valve Team decision to perform PCI pre-TAVR). We hypothesized that assessment of CADp on noncoronary gated TAVRCT would demonstrate a high negative predictive value (NPV) when judged against these criteria. One-hundred and ninety-two consecutive TAVR patients were included from May 2017 to March 2020. All patients underwent i) TAVRCT (GE Lightspeed 64-slice CT scanner), ii) pre-TAVR ICA, and iii) subsequent TAVR. TAVRCT scans were blind-reported (S.G.) to identify CADp (defined as a >50% diameter stenosis of the left-main stem, right coronary artery, or left anterior descending arteries 99% NPV for both) supports safe deferral of routine ICA in contemporary pre-procedural TAVR planning in favor of proximal coronary assessment on noncoronary gated TAVRCT (Figure 1). Additionally, the high NPV for both left and right proximal coronary systems provides reassurance that TAVRCT is seemingly effective at ruling out anatomically significant proximal coronary disease independent of proximal vessel territory.