Can Coronary CT Angiography Replace Invasive Coronary Angiography in Pre-TAVI Coronary Assessment?

Coronary artery disease coexists in approximately half of patients undergoing transcatheter aortic valve implantation, making coronary assessment prior to the procedure essential. Invasive coronary angiography remains the reference standard; however, coronary computed tomography angiography has demonstrated high accuracy in ruling out significant coronary artery disease and may reduce the need for invasive testing. 

In this context, the authors conducted a systematic review and meta-analysis to evaluate whether pre-TAVI coronary CT angiography can safely guide coronary assessment and decrease the use of invasive coronary angiography.

A total of 1,570 publications were identified, of which 5 studies met the inclusion criteria for the final analysis. All were cohort studies with one-year follow-up.

Overall, 3,073 patients were analyzed: 1,573 evaluated with coronary CT angiography and 1,500 with invasive coronary angiography. The mean age was 80.7 ± 7.3 years; 47.1% were women, and the prevalence of coronary artery disease was 48.95%. In most studies, only patients with proximal stenosis greater than 70%, left main stenosis greater than 50%, or non-diagnostic CT findings were referred for invasive coronary angiography.

Coronary CT Angiography Before TAVI: Reduces Invasive Coronary Angiography by More Than 50% Without Increasing One-Year Clinical Events

The use of coronary CT angiography allowed avoidance of invasive coronary angiography in 54.3% of patients and was associated with a significant reduction in planned percutaneous coronary intervention prior to TAVI (odds ratio 0.17; 95% confidence interval 0.03–0.91; p = 0.03). In absolute terms, 10.7% of patients in the CT group underwent pre-TAVI percutaneous coronary intervention, compared with 27.9% in the invasive angiography group.

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No significant differences were observed in major clinical events. Cardiac mortality, myocardial infarction, all-cause mortality, major adverse cardiovascular events, and the need for revascularization after TAVI were similar between both strategies. Event rates were low and comparable, with all-cause mortality of 8.7% in the CT group and 8.9% in the invasive angiography group (p = 0.41), and major adverse cardiovascular events of 10.8% and 12.8%, respectively (p = 0.55).

Conclusion: CCTA as a Safe Initial Strategy for Coronary Assessment Before TAVI

Pre-TAVI coronary assessment using coronary CT angiography allows avoidance of invasive coronary angiography in more than half of patients and is associated with clinical outcomes comparable to a routine invasive strategy at one year. Coronary CT angiography may be considered a safe initial strategy to rule out significant coronary artery disease in selected patients. However, the available evidence is based on a limited number of observational studies and requires confirmation in larger randomized trials.

Original Title: Pre-TAVI CT Angiography for Coronary Artery Disease Assessment: A Systematic Review and Meta-Analysis of Clinical Outcomes.