Ginkel, Dirk Jan van

Abstract Objectives To perform a systematic review and meta-analysis on diagnostic accuracy and other outcomes of coronary computed tomography angiography (CCTA) and CT-derived fractional flow reserve (CT-FFR) in candidates for trans-catheter aortic valve implantation (TAVI). Background Screening for obstructive coronary artery disease (CAD) with CCTA during TAVI work-up could prevent unnecessary invasive coronary angiography (ICA). This becomes increasingly relevant as the TAVI-population grows. CT-FFR improves CCTA accuracy in chest pain patients, but its reliability is unknown in the TAVI-population. 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 Twenty-four of the 29 included articles were part of the meta-analysis, reporting results for CCTA and CT-FFR in 3.494 and 797 patients respectively. Reference standard was anatomical severity of CAD in most studies. At patient-level, pooled CCTA sensitivity was 94.3% and specificity 74.8%. CT-FFR sensitivity was 91.5% and specificity 60.3% with strong variation between studies. CCTA correctly ruled out CAD in 52% of all patients, but 42% of positive CCTAs were false positives. CT-FFR correctly ruled out CAD in 47% of all patients included in this meta-analysis, but showed better accuracy than CCTA in studies that compared both. In these studies, sensitivity of CCTA versus CT-FFR was 70.7% versus 79.0% and specificity was 64.4% versus 92.9%. Conclusions Negative CCTA effectively rules-out CAD in the TAVI-population. Adding CCTA to TAVI work-up could lead to significant reduction in pre-TAVI ICA procedures, but the proportion of false-positives remains high. In studies performing a direct comparison, CT-FFR performed better than CCTA. This is not reflected in the CT-FFR meta-analysis. Therefore, diagnostic accuracy of CT-FFR and added value over CCTA in the TAVI-population remains unclear. Further research regarding validation and reliability is warranted.Meta-analysis of CCTA and CT-FFR

Abstract Objectives To assess the diagnostic performance of CT-FFR for the diagnosis of CAD in the work-up for TAVI. Background Work-up for transcatheter aortic valve implantation (TAVI) currently utilizes computed tomography (CT) to evaluate annulus diameter and peripheral vascular access, plus invasive coronary angiography (ICA) to assess significant coronary artery disease (CAD). ICA might partially be redundant with the use of Coronary CT Angiography (CCTA). Prior studies found improvement of the diagnostic accuracy of CCTA by use of CT derived fractional flow reserve (CT-FFR). Methods Consecutive patients with severe symptomatic aortic valve stenosis who underwent TAVI work-up between 2015–2019 were included in this cross-sectional study. All patients underwent CCTA and ICA within 3 months and diagnostic performance of both CCTA and CT-FFR were assessed using ICA as reference. Results Seventy-six of the 338 patients included in the analysis had ≥1 significant coronary stenosis at ICA. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy per-patient were 76.9%, 64.5%, 34.0%, 92.1% and 66.9% for CCTA and 84.6%, 88.3%, 63.2%, 96.0% and 87.6% for CT-FFR. The area under the receiver-operating characteristic-curve significantly differ between CCTA and CT-FFR (0.84 versus 0.90 p=0.02). A CT-FFR guided approach could avoid ICA in 57.1% versus 43.6% using CCTA. Conclusions CT-FFR significantly improves the diagnostic accuracy of CCTA without additional testing and increases the proportion of patients in whom ICA could have been safely avoided It has the potential to be integrated in the current clinical work-up for TAVI for diagnosing stable CAD requiring treatment. Funding Acknowledgement Type of funding sources: None.