Coronary CT angiography instead of invasive angiography before TAVI: Feasibility and outcomes.

Concomitant coronary artery disease (CAD) is frequent in transcatheter aortic valve implantation (TAVI) candidates. Despite societal recommendations of performing invasive coronary angiography (ICA) for coronary assessment in the pre-TAVI diagnostic workup, the prognostic value of ICA and beneficial effect of revascularization in these patients remains unclear. We aimed to determine feasibility and outcomes following a strategy of cardiac CT + coronary CT angiography (cCTA) rather than cardiac CT + ICA before TAVI. We performed a single-center, observational cohort study including all patients, without previous coronary intervention, referred to TAVI between April 2020 and November 2021. CAD was assessed by cCTA, and only patients with proximal stenosis >70 %, or left main stenosis >50 %, or cCTA was non-evaluable regarding proximal segments were subsequently referred to ICA. 240 patients were included in the study. No adverse effects to pre-cCTA-scan nitroglycerin administration were observed. On cCTA, 92 % of the patients had atheroscerosis. 191 (80 %) patients had cCTA only performed, while 49 (20 %) patients underwent subsequent ICA. During a median (range) follow-up of 15 (6-25) months, no difference in procedural complication rates, mortality rates, or number of unplanned ICA was observed between patients evaluated with only cCTA vs cCTA+ICA. Upfront cCTA instead of ICA for assessment of obstructive CAD in the diagnostic workup of patients with severe aortic stenosis referred to TAVI is feasible, safe, and with similar procedural and clinical outcomes. Randomized studies are warranted to further validate the safety of using CTA rather than ICA for coronary assessment in TAVI candidates.

Jensen RV ，Jensen JM ，Iraqi N ，Grove EL ，Mathiassen ON ，Pedersen KB ，Parner E ，Leipsic J ，Terkelsen CJ ，Nørgaard BL ... -  《-》

Coronary CTA and CT-FFR in trans-catheter aortic valve implantation candidates: a systematic review and meta-analysis.

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. 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. 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%. 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. 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.

Becker LM ，Peper J ，van Ginkel DJ ，Overduin DC ，van Es HW ，Rensing BJMW ，Timmers L ，Ten Berg JM ，Mohamed Hoesein FAA ，Leiner T ，Swaans MJ ... -  《-》

TransCatheter aortic valve implantation and fractional flow reserve-guided percutaneous coronary intervention versus conventional surgical aortic valve replacement and coronary bypass grafting for treatment of patients with aortic valve stenosis and compl

Patients with severe aortic stenosis present frequently (∼50%) with concomitant obstructive coronary artery disease. Current guidelines recommend combined surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) as the preferred treatment. Transcatheter aortic valve implantation (TAVI) and fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) represent a valid treatment alternative. We aimed to test the non-inferiority of FFR-guided PCI plus TAVI versus SAVR plus CABG in patients with severe aortic stenosis and complex coronary artery disease. This international, multicentre, prospective, open-label, non-inferiority, randomised controlled trial was conducted at 18 tertiary medical centres across Europe. Patients (aged ≥70 years) with severe aortic stenosis and complex coronary artery disease, deemed feasible for percutaneous or surgical treatment according to the on-site Heart Team, were randomly assigned (1:1) to FFR-guided PCI plus TAVI or SAVR plus CABG according to a computer-generated sequence with random permuted blocks sizes stratified by site. The primary endpoint was a composite of all-cause mortality, myocardial infarction, disabling stroke, clinically driven target-vessel revascularisation, valve reintervention, and life-threatening or disabling bleeding at 1 year post-treatment. The trial was powered for non-inferiority (with a margin of 15%) and if met, for superiority. The primary and safety analyses were done per an intention-to-treat principle. This trial is registered with ClinicalTrials.gov (NCT03424941) and is closed. Between May 31, 2018, and June 30, 2023, 172 patients were enrolled, of whom 91 were assigned to the FFR-guided PCI plus TAVI group and 81 to the SAVR plus CABG group. The mean age of patients was 76·5 years (SD 3·9). 118 (69%) of 172 patients were male and 54 (31%) patients were female. FFR-guided PCI plus TAVI resulted in favourable outcomes for the primary endpoint (four [4%] of 91 patients) versus SAVR plus CABG (17 [23%] of 77 patients; risk difference -18·5 [90% CI -27·8 to -9·7]), which was below the 15% prespecified non-inferiority margin (pnon-inferiority<0·001). FFR-guided PCI plus TAVI was superior to SAVR plus CABG (hazard ratio 0·17 [95% CI 0·06-0·51]; psuperiority<0·001), which was driven mainly by all-cause mortality (none [0%] of 91 patients vs seven (10%) of 77 patients; p=0·0025) and life-threatening bleeding (two [2%] vs nine [12%]; p=0·010). The TCW trial is the first trial to compare percutaneous treatment versus surgical treatment in patients with severe aortic stenosis and complex coronary artery disease, showing favourable primary endpoint and mortality outcomes with percutaneous treatment. Isala Heart Centre and Medtronic.

Kedhi E ，Hermanides RS ，Dambrink JE ，Singh SK ，Ten Berg JM ，van Ginkel D ，Hudec M ，Amoroso G ，Amat-Santos IJ ，Andreas M ，Campante Teles R ，Bonnet G ，Van Belle E ，Conradi L ，van Garsse L ，Wojakowski W ，Voudris V ，Sacha J ，Cervinka P ，Lipsic E ，Somi S ，Nombela-Franco L ，Postma S ，Piayda K ，De Luca G ，Kolkman E ，Malinowski KP ，Modine T ，TCW study group ... -  《-》

On-site CT-derived cFFR in patients with suspected coronary artery disease: Feasibility on a 128-row CT scanner in everyday clinical practice.

Technical feasibility of CT-based calculation of fractional flow reserve (cFFR) using a 128-row computed tomography scanner in an everyday routine setting. Post-processing and everyday practicability should be analyzed on the scanner on-site in connection with clinical parameters. This single-center retrospective analysis included 230 patients (74 female; mean age 63.8 years) with CCTA within 21 months between 01/2018 and 09/2019 without non-pathological examinations. cFFR values were obtained using a deep learning-based non-commercial research prototype (cFFR Version3.5.0; Siemens Healthineers GmbH, Erlangen). cFFR values were evaluated at two points: at the maximum point of the stenosis and 1.0 cm distal to the stenosis. Comparison with invasive coronary angiography in 57/230 patients (24.7 %) was performed. CT parameters and quality were evaluated. Further subgroup classification concerning criteria of technical postprocessing was performed: no changes necessary, minor corrections necessary, major corrections necessary, and no evaluation was possible. The required time from starting the software to the final result was evaluated. A total of 116/448 (25.9 %) mild, 223/448 (49.8 %) moderate, and 109/448 (24.3 %) obstructive stenoses was found. The mean cFFR at the maximum point of the stenosis was 0.92 ± 0.09 and significantly higher than the cFRR value of 0.89 ± 0.13 distal to the stenosis (p < 0.001*). The mean degree of stenosis was 44.02 ± 26.99 % (range: 1-99 %) with an area of 5.39 ± 3.30 mm2. In a total of 45 patients (19.1 %), a relevant reduction in cFFR below 0.80 was determined. Overall, in 57/230 patients (24.8 %), catheter angiography was performed. No significant difference in the degree of maximal stenosis (CAD-RADS 0-2/3/4) was detected between the classification of CCTA and ICA (p = 0.171). The mean post-processing time varied significantly with 8.34 ± 4.66 min. in single-vessel CAD vs. 12.91 ± 3.92 min. in two-vessel CAD vs. 21.80 ± 5.94 min. in three-vessel CAD (each p < 0.001). Noninvasive onsite quantification of cFFR is feasible with minimal observer interaction in a routine real-world setting on a 128-row scanner. Deep learning-based algorithms allow a robust and semi-automatic on-site determination of cFFR based on data from standard CT scanners. · Non-invasive on-site quantification of cFFR is feasible with minimal observer interaction.. · Deep-learning based algorithms allow robust and semi-automatic on-site determination of cFFR.. · The mean follow-up time varied significantly with the extent of vascular CAD..

Baumeister T ，Kloth C ，Schmidt SA ，Kloempken S ，Brunner H ，Buckert D ，Bernhardt P ，Panknin C ，Beer M ... -  《-》

When to perform percutaneous coronary interventions in TAVI patients? Recent advances.

Lunardi M ，Bianchini F ，Aurigemma C ，Romagnoli E ，Paraggio L ，Bianchini E ，Zito A ，Trani C ，Burzotta F ... -  《-》