Optimizing transcatheter aortic valve implantation work-up: the role of preprocedural computed tomography for the screening of concomitant coronary artery disease

Transcatheter aortic valve implantation (TAVI) has proven to be an excellent treatment modality for patients with severe aortic valve stenosis. Improved preprocedural planning, refinements of procedural techniques, and increased operator’s experience have contributed to overcome early challenges, and led to the widespread use of TAVI. The annual number of patients undergoing TAVI is now exceeding that of patients undergoing conventional surgical aortic valve replacement (1).

Nevertheless, there are still some important issues to be resolved. One of these challenges is treatment of concomitant coronary artery disease (CAD). Aortic valve stenosis shares various risk factors with CAD accompanied by similarities in pathophysiology (2). The precise incidence of CAD is uncertain but is believed to affect a substantial number of patients undergoing TAVI with incidence ranging between 20% and 80% (3). The presence of concomitant CAD in patients undergoing TAVI may affect clinical outcomes, and thus international guidelines recommend to assess the presence and severity of concomitant CAD before TAVI (4). However, the importance of revascularization in those patients presenting with both severe aortic valve stenosis and CAD is controversial. Current guidelines advocate that revascularization of proximal segments should be considered before TAVI, but the scientific evidence for this recommendation is weak (4). Indeed, multiple studies have failed to show a significant benefit of percutaneous coronary intervention (PCI) on mortality in patients undergoing TAVI, but evidence from randomized clinical trials is limited (5-8). However, major bleeding complications are more prevalent in patients undergoing PCI before TAVI, which is associated with higher mortality risk after TAVI (9).

Invasive coronary angiography remains the cornerstone for the assessment of CAD in most TAVI centers. Importantly, invasive coronary angiography has multiple disadvantages including the risk of periprocedural complications, and healthcare costs. Additionally, evaluation of CAD by invasive coronary angiography is only one of multiple (diagnostic) assessments that elderly patients need to undergo during routine work-up for TAVI. Computed tomography (CT) has been suggested as an alternative for the screening and evaluation of concomitant CAD in patients planned to undergo TAVI. CT is already part of routine work-up for TAVI as it is used for the assessment of vascular access, aortic root anatomy and valve characteristics. Validation of CT for the evaluation of concomitant CAD in patients undergoing TAVI may reduce the number of patients that require invasive coronary angiography before TAVI.

In this issue of Diagnostic and Interventional Imaging, Lecomte et al. evaluated the percentage of coronary angiography that can be avoided by reconstruction of the coronary arteries on preprocedural CT (10). Therefore, they screened 329 consecutive patients who were referred for TAVI between December 2021 and July 2022. A total of 206 patients fulfilled all prespecified study criteria, including the availability of both preprocedural CT and coronary angiography. More than one third (n=123) of the screened patients was excluded. Out of these 123 patients, 70 patients were excluded as they had a history of coronary revascularization. The presence of concomitant CAD was assessed by a junior radiologist, and reassessed by an experienced cardiac radiologist for interobserver variability. Next, these results were compared with the findings on coronary angiography and the decision of the interventionalists to perform coronary revascularization before TAVI. Lecomte et al. (10) describe that the quality of 155 (70%) preprocedural CT scans was sufficient for the evaluation of concomitant CAD. Interobserver variability was substantial. Based on their findings on CT, Lecomte et al. (10) would have referred 58 (37%) patients for invasive coronary angiography. Of these, 27 patients had concomitant CAD requiring coronary revascularization. Invasive coronary angiography did not reveal concomitant CAD requiring coronary revascularization in any of the patients who would not have been recommended to undergo invasive coronary based on preprocedural CT. These results show that preprocedural CT has a very high negative predictive value for ruling out concomitant CAD. Therefore, Lecomte et al. (10) conclude that the use of preprocedural CT may potentially avoid the need for invasive coronary angiography in a large number of patients undergoing TAVI.

The conclusion of Lecomte et al. (10) is in line with those of previous studies on the use of CT as a screening tool for concomitant CAD in patients undergoing TAVI (11-13). However, the current study also highlights various drawbacks of CT as a screening tool for concomitant CAD in patients referred for TAVI. Firstly, CT image quality was insufficient for evaluation of concomitant CAD in one third of the included patients. This problem can be attributed to several aspects including poor breath-hold ability and the high incidence of arrhythmias in patients referred for TAVI. Secondly, patients undergoing TAVI are often characterized by a substantial coronary artery calcium burden, frequently causing so-called blooming artefacts. These blooming artefacts are associated with overestimation of coronary stenosis, leading to a significant number of false positives. In addition, the current study excluded a large number of patients with a history of coronary revascularization due to similar difficulties as in patients with highly calcified CAD. As such, invasive coronary angiography may remain inevitable in these patients. Nonetheless, future technical refinements of CT scanners and protocols are likely to reduce the number of false positives. The latter was confirmed by a recent study by Kondoleon et al. that showed that improved technology and protocols led to a significantly improved positive predictive value of 83% for CT for detecting high-grade proximal stenoses in patients referred for TAVI (12).

In conclusion, the study by Lecomte et al. (10) perfectly demonstrates the high potential of CT as a screening tool for concomitant CAD in patients planned to undergo TAVI, but robust evidence for randomization clinical trials is warranted. The implementation of CT to rule out concomitant CAD may further streamline the work-up for TAVI, and will ease the burden of standard preprocedural diagnostic assessments for the frail TAVI patient, accompanied by a significant reduction in healthcare costs.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article has undergone external peer review.

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-182/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-182/coif). R.D. received educational grants from Boston Scientific, Biomed, Edwards Lifesciences, Sanofi, Meril Life Science, Novartis, and Amgen. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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