Coronary CTA may be a safe and effective alternative to invasive coronary angiography for patients with severe aortic stenosis undergoing evaluation for transcatheter aortic valve replacement, according to recent findings.
Researchers retrospectively evaluated 491 patients with severe aortic stenosis treated with TAVR at the San Raffaele Scientific Institute in Milan between November 2007 and September 2014. All patients were imaged with coronary CTA to screen for CAD. After completion of a successful CTA scan, invasive coronary vascular scans were performed for cases in which CTA had revealed a suspicious coronary lesion that warranted further investigation, or severe coronary calcifications or moving artifacts had prevented proper evaluation of coronary anatomy.
The primary outcome of interest was major adverse cardiac and cerebrovascular events, including death, MI, cerebrovascular events and revascularization due to ischemia, at 30 days and 1 year post-TAVR. Specifically, the researchers compared the incidence of MACCE among patients who underwent CTA as their sole screening modality (n = 375; 76.3%) vs. those who also received invasive coronary angiography (n = 116; 21.7%).
The two groups did not differ significantly with regard to unadjusted 30-day rates of MACCE (4% in CTA-only patients vs. 5.2% in patients who also underwent invasive coronary angiography; P = .42). Similarly, no differences were observed between the groups in unadjusted MACCE rates at 1 year (15.4% vs. 18.1%; P = .61). Rates of all-cause mortality and CV mortality, as well as the number of postprocedural discharge days, did not differ according to treatment.
These findings persisted after multivariable adjustment for baseline and clinical confounders, with no increased risk for MACCE observed for patients who received CTA alone at either 30 days (HR = 1.08; 95% CI, 0.44-2.7) or 1 year (HR = 0.89; 95% CI, 0.49-1.6).
According to the researchers, these findings warrant prospective studies into the potential role of CTA in pre-TAVR screening.
“[Coronary CTA] coupled to cardiac CT scan used as a routine, noninvasive, diagnostic screening tool for CAD in patients with severe [aortic stenosis] undergoing TAVR seems to be safe and effective, allowing with a single test the acquisition of a wide range of information on aortic annulus, peripheral access sites and coronary anatomy,” the researchers wrote. “Performing [coronary angiography] only when absolutely necessary could lead to improved outcomes, reductions in the overall procedural cost and hospitalization time.” – by Jennifer Byrne
Disclosure: Three of the researchers report being a proctor, advisory board member or shareholder in Direct Flow Medical, Edwards Lifesciences and Medtronic.