Feasibility of Computed Tomography as a Gatekeeper for Invasive Angiography before TAVR: A Pragmatic Real-World Experience

Abstract

BACKGROUND: Although pretranscatheter aortic valve replacement-computed tomography angiography (TAVR-CTA) has shown a good correlation with invasive coronary angiography (ICA) for ruling out obstructive coronary artery disease (CAD), its clinical effectiveness and safety as a gatekeeper for ICA pre-transcatheter aortic valve replacement (pre-TAVR) remain unclear. This study aims to determine whether routine TAVR-CTA, without premedication, could safely defer and guide the need for ICA pre-TAVR. METHODS: Patients who underwent TAVR evaluation with either TAVR-CTA or ICA to determine CAD between 2017 and 2022 were included. Patients with prior coronary artery bypass grafts were excluded, and the remaining patients were divided into CAD screening with TAVR-CTA or ICA groups. The primary outcome was symptom-driven revascularization at 1 year post-TAVR. RESULTS: Among 1165 patients (median age, 81 years; 46% women), 464 were in TAVR-CTA group and 701 were in the ICA group. Prevalence of CAD was similar (37% versus 41%; P=0.2). A total of 53% of patients were exempted from ICA after TAVR-CTA, given the absence of proximal obstructive CAD, whereas 17% had inconclusive TAVR-CTA interpretation, 15% desired for ICA despite CAD exclusion by TAVR-CTA, and 14% had obstructive CAD requiring further ICA. Elevated coronary artery calcium score and the presence of stents were associated with need for ICA after TAVR-CTA. TAVR-CTA revealed a per-patient sensitivity of 89%, specificity of 75%, positive predictive value of 69%, and negative predictive value of 91% for identifying obstructive CAD. Importantly, symptom-driven revascularization, acute coronary syndrome, and unplanned ICA at 1 year after TAVR were all low and not different between TAVR-CTA versus ICA (0.8% versus 1.8%, P=0.158; 1.6% versus 1.7%, P=0.846; 2.7% versus 2.8%, P=0.767; respectively). CONCLUSIONS: In comparison with routine ICA pre-TAVR, integration of TAVR-CTA in our program resulted in up to 53% of patients exempted from ICA, while maintaining patient safety. This approach could have important clinical implications to improve patient access, experience, value, and throughput.