Targeted exclusion of proximal obstructive coronary disease on coronary computed tomography angiography for deferral of routine invasive coronary angiography prior to transcatheter aortic valve replacement
Alalwan Y, Coriasso N, Aljamal A, Hughes CL, Abdelrahim E, Dee Wang D, Pantelic M, Song T, Eng MH, Frisoli T, Villablanca P, Wyman JF, O'Neill WW, and Lee J. Targeted exclusion of proximal obstructive coronary disease on coronary computed tomography angiography for deferral of routine invasive coronary angiography prior to transcatheter aortic valve replacement. Catheterization and Cardiovascular Interventions 2020; 95:S115.
Catheterization and cardiovascular interventions
Background: Aortic stenosis is associated with coronary artery disease (CAD) and routine invasive coronary angiography (ICA) is performed prior to transcatheter aortic valve replacement (TAVR). Evaluation of CAD on computed tomography angiography (CTA) is limited due to coronary calcification, cardiac motion and absence of sublingual nitroglycerin but may be feasible for the exclusion of only proximal CAD.
Methods: 339 patients (52% male, age 79 ± 27) who underwent TAVR between 5/1/18 and 12/20/18 were retrospectively studied. Routine pre-procedure ECG-gated CTA was performed with reconstruction phases in 10% increments. CTA evaluation of proximal CAD performed clinically on request from multidisciplinary heart team. CAD analysis performed on 3D workstations by experienced cardiologists and radiologists. Stenosis grades: 0=normal, 1=1-25%, 2=26-50%, 3=51-70%, 4=71-99%, 5=occluded, 8=absent, 9=uninterpretable.
Results: Of 339 patients, 62 (18%) patients had CTA coronary analysis of which 49 (14%) also had ICA before or at time of TAVR. Of these patients, 21 (43%) patients had no stenosis more than 50% on CTA, and of those 21 patients, 19 (91%) also had no stenosis more than 50% on ICA. 28 patients who had both ICA and CTA had ≥50% stenosis in at least one coronary artery on CTA. Of these, 22 (79%) also had ≥50% stenosis on ICA. When excluding those with coronary artery bypass grafts (12 patients), 63% of patients had ≥50% stenosis on both CTA and ICA.13 patients had CTA without follow up ICA. Overall including all patients with no CAD on ICA and those who were deferred ICA based on CTA results, 32 (52%) patients avoided or could have avoided ICA, leading to a total theoretical cost saving of $155,000-310,000. No patients had acute coronary syndrome (ACS) at the time of discharge post TAVR.
Conclusions: Exclusion of proximal obstructive CAD on routine pre- TAVR CTA is feasible and can decrease utilization of ICA with no increase in ACS at the time discharge post TAVR implantation. This strategy can decrease invasive procedures and potentially reduce cost. Further study is needed on longitudinal outcomes with this strategy.