Coronary CTA and CT-FFR in Trans-catheter Aortic Valve Implantation Candidates: a Systematic Review and Meta-analysis

Overview

Journal Eur Radiol

Specialty Radiology

Date 2024 Dec 31

PMID 39738560

Authors

Leonie M Becker

Joyce Peper

Dirk-Jan van Ginkel

Daniel C Overduin

Hendrik W van Es

Benno J M W Rensing

Leo Timmers

Jurrien M Ten Berg

Firdaus A A Mohamed Hoesein

Tim Leiner

Martin J Swaans

Affiliations

Soon will be listed here.

Abstract

Objectives: Screening for obstructive coronary artery disease (CAD) with coronary computed tomography angiography (CCTA) could prevent unnecessary invasive coronary angiography (ICA) procedures during work-up for trans-catheter aortic valve implantation (TAVI). CT-derived fractional flow reserve (CT-FFR) improves CCTA accuracy in chest pain patients. However, its reliability in the TAVI population is unknown. This systematic review and meta-analysis assesses CCTA and CT-FFR in TAVI candidates.

Methods: PubMed, Embase and Web of Science were searched for studies regarding CCTA and/or CT-FFR in TAVI candidates. Primary endpoint was correct identification and rule-out of obstructive CAD. Results were pooled in a meta-analysis.

Results: Thirty-four articles were part of the meta-analysis, reporting results for CCTA and CT-FFR in 7235 and 1269 patients, respectively. Reference standard was mostly anatomical severity of CAD. At patient level, pooled CCTA sensitivity was 94.0% and specificity 72.4%. CT-FFR sensitivity was 93.2% and specificity 70.3% with substantial variation between studies. However, in studies that compared both, CT-FFR performed better than CCTA. Sensitivity of CCTA versus CT-FFR was 74.9% versus 83.9%, and specificity was 65.5% versus 89.8%.

Conclusions: Negative CCTA accurately rules out CAD in the TAVI population. CCTA could lead to significant reduction in pre-TAVI ICA, but false positives remain high. Diagnostic accuracy of CT-FFR was comparable to that of CCTA in our meta-analyses, but in studies performing a direct comparison, CT-FFR performed better than CCTA. However, as most studies were small and used CT-FFR software exclusively available for research, a large study on CT-FFR in TAVI work-up using commercially available CT-FFR software would be appropriate before considering routine implementation.

Key Points: Question Coronary artery disease (CAD) screening with invasive coronary angiography before trans-catheter aortic valve implantation (TAVI) is often retrospectively unnecessary, revealing no obstructive CAD. Findings Coronary CTA ruled out CAD in approximately half of TAVI candidates. CT-derived fractional flow reserve (CT-FFR) performed similarly overall but better than coronary CTA in direct comparison. Clinical relevance Addition of coronary CTA to TAVI planning-CT to screen for obstructive CAD could reduce negative invasive coronary angiographies in TAVI work-up. CT-FFR could reduce false-positive coronary CTA results, improving its gatekeeper function in this population, but more data is necessary.

References

Ahmad Y, Howard J, Arnold A, Madhavan M, Cook C, Alu M . Transcatheter versus surgical aortic valve replacement in lower-risk and higher-risk patients: a meta-analysis of randomized trials. Eur Heart J. 2023; 44(10):836-852. DOI: 10.1093/eurheartj/ehac642. View

Peper J, Becker L, van den Berg H, Bor W, Brouwer J, Nijenhuis V . Diagnostic Performance of CCTA and CT-FFR for the Detection of CAD in TAVR Work-Up. JACC Cardiovasc Interv. 2022; 15(11):1140-1149. DOI: 10.1016/j.jcin.2022.03.025. View

Renker M, Steinbach R, Schoepf U, Fischer-Rasokat U, Choi Y, Hamm C . Comparison of First-generation and Third-generation Dual-source Computed Tomography for Detecting Coronary Artery Disease in Patients Evaluated for Transcatheter Aortic Valve Replacement. J Thorac Imaging. 2023; 38(3):165-173. DOI: 10.1097/RTI.0000000000000699. View

Andreini D, Pontone G, Mushtaq S, Bartorelli A, Ballerini G, Bertella E . Diagnostic accuracy of multidetector computed tomography coronary angiography in 325 consecutive patients referred for transcatheter aortic valve replacement. Am Heart J. 2014; 168(3):332-9. DOI: 10.1016/j.ahj.2014.04.022. View

Paradis J, Fried J, Nazif T, Kirtane A, Harjai K, Khalique O . Aortic stenosis and coronary artery disease: what do we know? What don't we know? A comprehensive review of the literature with proposed treatment algorithms. Eur Heart J. 2014; 35(31):2069-82. DOI: 10.1093/eurheartj/ehu247. View

Schicchi N, Fogante M, Esposto Pirani P, Agliata G, Piva T, Tagliati C . Third generation dual source CT with ultra-high pitch protocol for TAVI planning and coronary tree assessment: feasibility, image quality and diagnostic performance. Eur J Radiol. 2019; 122:108749. DOI: 10.1016/j.ejrad.2019.108749. View

Opolski M, Kim W, Liebetrau C, Walther C, Blumenstein J, Gaede L . Diagnostic accuracy of computed tomography angiography for the detection of coronary artery disease in patients referred for transcatheter aortic valve implantation. Clin Res Cardiol. 2015; 104(6):471-80. DOI: 10.1007/s00392-014-0806-z. View

Shuai T, Li W, You Y, Deng L, Li J, Peng L . Combined Coronary CT Angiography and Evaluation of Access Vessels for TAVR Patients in Free-Breathing with Single Contrast Medium Injection Using a 16-cm-Wide Detector CT. Acad Radiol. 2020; 28(12):1662-1668. DOI: 10.1016/j.acra.2020.08.003. View

Pontone G, Andreini D, Bartorelli A, Annoni A, Mushtaq S, Bertella E . Feasibility and accuracy of a comprehensive multidetector computed tomography acquisition for patients referred for balloon-expandable transcatheter aortic valve implantation. Am Heart J. 2011; 161(6):1106-13. DOI: 10.1016/j.ahj.2011.03.003. View

10.

Michail M, Ihdayhid A, Comella A, Thakur U, Cameron J, McCormick L . Feasibility and Validity of Computed Tomography-Derived Fractional Flow Reserve in Patients With Severe Aortic Stenosis: The CAST-FFR Study. Circ Cardiovasc Interv. 2020; 14(1):e009586. PMC: 7116852. DOI: 10.1161/CIRCINTERVENTIONS.120.009586. View

11.

Peper J, Becker L, Van Kuijk J, Leiner T, Swaans M . Fractional Flow Reserve: Patient Selection and Perspectives. Vasc Health Risk Manag. 2021; 17:817-831. PMC: 8684425. DOI: 10.2147/VHRM.S286916. View

12.

Narula J, Chandrashekhar Y, Ahmadi A, Abbara S, Berman D, Blankstein R . SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr. 2020; 15(3):192-217. PMC: 8713482. DOI: 10.1016/j.jcct.2020.11.001. View

13.

Gohmann R, Pawelka K, Seitz P, Majunke N, Heiser L, Renatus K . Combined cCTA and TAVR Planning for Ruling Out Significant CAD: Added Value of ML-Based CT-FFR. JACC Cardiovasc Imaging. 2021; 15(3):476-486. DOI: 10.1016/j.jcmg.2021.09.013. View

14.

Brooke B, Schwartz T, Pawlik T . MOOSE Reporting Guidelines for Meta-analyses of Observational Studies. JAMA Surg. 2021; 156(8):787-788. DOI: 10.1001/jamasurg.2021.0522. View

15.

Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A . Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016; 5(1):210. PMC: 5139140. DOI: 10.1186/s13643-016-0384-4. View

16.

Whiting P, Rutjes A, Westwood M, Mallett S, Deeks J, Reitsma J . QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011; 155(8):529-36. DOI: 10.7326/0003-4819-155-8-201110180-00009. View

17.

Reitsma J, Glas A, Rutjes A, Scholten R, Bossuyt P, Zwinderman A . Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol. 2005; 58(10):982-90. DOI: 10.1016/j.jclinepi.2005.02.022. View

18.

Sasaki S, Kawamori H, Toba T, Takeshige R, Fukuyama Y, Hiromasa T . Diagnostic Accuracy of Pre-Transcatheter Aortic Valve Replacement Nitroglycerin-Free Fractional Flow Reserve-Computed Tomography-Based Physiological Assessment in Patients With Severe Aortic Stenosis for Predicting Post-Transcatheter Aortic Valve.... Circ J. 2023; 88(4):501-509. DOI: 10.1253/circj.CJ-23-0312. View

19.

Kondoleon N, Layoun H, Spilias N, Sipko J, Kanaan C, Harb S . Effectiveness of Pre-TAVR CTA as a Screening Tool for Significant CAD Before TAVR. JACC Cardiovasc Interv. 2023; 16(16):1990-2000. DOI: 10.1016/j.jcin.2023.05.030. View

20.

Khan S, Gedela S, Frost O, Galinato M, Crawford I, Smith S . Noncoronary Gated Transcatheter Aortic Valve Replacement Computed Tomography Scans Can Safely Replace Invasive Coronary Angiography Pre-Transcatheter Aortic Valve Replacement. Struct Heart. 2023; 7(1):100123. PMC: 10236888. DOI: 10.1016/j.shj.2022.100123. View