Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2020 May 27;9(6):1623.
doi: 10.3390/jcm9061623.

Combined Coronary CT-Angiography and TAVI-Planning: A Contrast-Neutral Routine Approach for Ruling-out Significant Coronary Artery Disease

Robin F Gohmann  1   2 , Philipp Lauten  3 , Patrick Seitz  1 , Christian Krieghoff  1 , Christian Lücke  1 , Sebastian Gottschling  1 , Meinhard Mende  4 , Stefan Weiß  5 , Johannes Wilde  3 , Philipp Kiefer  6 , Thilo Noack  6 , Steffen Desch  3   5 , David Holzhey  6 , Michael A Borger  5   6 , Holger Thiele  3   5 , Mohamed Abdel-Wahab  3   5 , Matthias Gutberlet  1   2   5
Affiliations

Combined Coronary CT-Angiography and TAVI-Planning: A Contrast-Neutral Routine Approach for Ruling-out Significant Coronary Artery Disease

Robin F Gohmann et al. J Clin Med. .

Abstract

Background: Significant coronary artery disease (CAD) is a common finding in patients undergoing transcatheter aortic valve implantation (TAVI). Assessment of CAD prior to TAVI is recommended by current guidelines and is mainly performed via invasive coronary angiography (ICA). In this study we analyzed the ability of coronary CT-angiography (cCTA) to rule out significant CAD (stenosis ≥ 50%) during routine pre-TAVI evaluation in patients with high pre-test probability for CAD.

Methods: In total, 460 consecutive patients undergoing pre-TAVI CT (mean age 79.6 ± 7.4 years) were included. All patients were examined with a retrospectively ECG-gated CT-scan of the heart, followed by a high-pitch-scan of the vascular access route utilizing a single intravenous bolus of 70 ml iodinated contrast medium. Images were evaluated for image quality, calcifications, and significant CAD; CT-examinations in which CAD could not be ruled out were defined as positive (CAD+). Routinely, patients received ICA (388/460; 84.3%; Group A), which was omitted if renal function was impaired and CAD was ruled out on cCTA (Group B). Following TAVI, clinical events were documented during the hospital stay.

Results: cCTA was negative for CAD in 40.2% (188/460). Sensitivity, specificity, PPV, and NPV in Group A were 97.8%, 45.2%, 49.6%, and 97.4%, respectively. Median coronary artery calcium score (CAC) was higher in CAD+-patients but did not have predictive value for correct classification of patients with cCTA. There were no significant differences in clinical events between Group A and B.

Conclusion: cCTA can be incorporated into pre-TAVI CT-evaluation with no need for additional contrast medium. cCTA may exclude significant CAD in a relatively high percentage of these high-risk patients. Thereby, cCTA may have the potential to reduce the need for ICA and total amount of contrast medium applied, possibly making pre-procedural evaluation for TAVI safer and faster.

Keywords: aortic stenosis; computed tomography coronary angiography; coronary angiography; coronary artery disease; diagnostic accuracy; transcatheter aortic valve implantation.

PubMed Disclaimer

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flow-chart of the study population according to diagnostics received: Group A underwent cCTA and ICA; Group B underwent cCTA only. CABG = coronary artery bypass graft, CAD− = no significant CAD on cCTA, CAD+ = significant CAD (stenosis ≥ 50%) on cCTA, cCTA = coronary CT-angiography, ICA = invasive coronary angiography, PCI = percutaneous coronary intervention, TAVI = transcatheter aortic valve implantation.
Figure 2
Figure 2
Dot-plot of patient’s CAC and their classification according to cCTA against invasive coronary angiography with QCA. Note the vast overlap of true negative and false positive results in relationship to CAC. The threshold (red dashed line) drawn at a CAC of 110 would exclude all false negative results as well as most true negative results. CAC = coronary artery calcium score, FN = false negative, FP = false positive, TN = true negative, TP = true positive, QCA = quantitative coronary analysis.
Figure 3
Figure 3
False negative (per vessel) cCTA example (CAC = 2839): Right coronary artery (RCA) with heavy calcifications and excellent contrast opacification (approx. 600 HU) on cCTA with multiplanar reconstruction (a) and volume rendered technique (b) and invasive coronary angiography depicting a ≥ 50% stenosis in the distal RCA (segment 3) (arrows) (c,d), which is masked on cCTA. CAC = coronary artery calcium score.
Figure 4
Figure 4
True positive cCTA example (CAC = 1235): Curved multiplanar reconstruction of the left circumflex artery (LCX) with non-calcified plaque and stenosis of 70% (arrow) in the distal LCX (segment 13) and a calcified plaque (arrowhead) in the proximal LCX (segment 11) (a). Corresponding projection of the invasive coronary angiography well depicting the stenosis (arrow); note the calcified non-stenotic plaque is not visible (b). CAC = coronary artery calcium score.
Figure 5
Figure 5
True negative cCTA example (CAC = 1834): Heavily calcified trifurcation of the left main (LM) into left anterior descending (LAD), left circumflex (LCX) and intermediate artery without luminal obstruction depicted as curved multiplanar reformation (a), volume rendered technique (b) and corresponding projection of invasive coronary angiography (c). CAC = coronary artery calcium score.
See this image and copyright information in PMC

References

    1. Baumgartner H., Falk V., Bax J.J., de Bonis M., Hamm C., Holm P.J., Iung B., Lancellotti P., Lansac E., Rodriguez Muñoz D., et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur. Heart J. 2017;38:2739–2791. doi: 10.1093/eurheartj/ehx391. - DOI - PubMed
    1. Nishimura R.A., Otto C.M., Bonow R.O., Carabello B.A., Erwin J.P., Fleisher L.A., Jneid H., Mack M.J., McLeod C.J., O’Gara P.T., et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J. Am. Coll. Cardiol. 2017;70:252–289. doi: 10.1016/j.jacc.2017.03.011. - DOI - PubMed
    1. Mack M.J., Leon M.B., Thourani V.H., Makkar R., Kodali S.K., Russo M., Kapadia S.R., Malaisrie S.C., Cohen D.J., Pibarot P., et al. Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients. N. Engl. J. Med. 2019;380:1695–1705. doi: 10.1056/NEJMoa1814052. - DOI - PubMed
    1. Popma J.J., Deeb G.M., Yakubov S.J., Mumtaz M., Gada H., O’Hair D., Bajwa T., Heiser J.C., Merhi W., Kleiman N.S., et al. Transcatheter Aortic-Valve Replacement with a Self-Expanding Valve in Low-Risk Patients. N. Engl. J. Med. 2019;380:1706–1715. doi: 10.1056/NEJMoa1816885. - DOI - PubMed
    1. Blanke P., Weir-McCall J.R., Achenbach S., Delgado V., Hausleiter J., Jilaihawi H., Marwan M., Nørgaard B.L., Piazza N., Schoenhagen P., et al. Computed Tomography Imaging in the Context of Transcatheter Aortic Valve Implantation (TAVI)/Transcatheter Aortic Valve Replacement (TAVR): An Expert Consensus Document of the Society of Cardiovascular Computed Tomography. JACC Cardiovasc. Imaging. 2019;12:1–24. doi: 10.1016/j.jcmg.2018.12.003. - DOI - PubMed

LinkOut - more resources