TCT-652 Feasibility and utility of anatomical and physiological evaluation of coronary disease with cardiac CT in severe aortic stenosis (FUTURE-AS registry).

Abstract

Background: Coronary artery disease (CAD) is common in patients with severe aortic stenosis (AS) and may impact both procedural and long-term outcomes of transcatheter aortic valve replacement (TAVR). Computed tomography coronary angiography (CTCA) and CT-derived fractional flow reserve (FFRCT) are tools used to assess CAD. However, adoption in the TAVR population is limited due to safety concerns associated with the use of nitroglycerin and beta-blockers. The safety, accuracy, and utility of CTCA and FFRCT, optimized with these medications in patients with severe AS considered for TAVR, remains unestablished. Method(s): This international, multicenter, prospective registry included patients with severe AS referred for TAVR, who were assessed for CAD with CTCA and FFRCT. All patients received nitroglycerin and beta-blockers as needed to optimize image quality. Patients with severe left ventricular dysfunction, recent syncope/heart failure, critical hemodynamics, or prior revascularization were excluded. Significant CAD was defined as CTCA stenosis >=50% and FFRCT <=0.75. The primary endpoint was per-patient sensitivity and negative predictive value (NPV) of CTCA compared to invasive coronary angiography (ICA). Secondary endpoints included the specificity and positive predictive value (PPV) of CTCA and FFRCT, safety (hypotension or bradycardia), feasibility (non-evaluable rate), the utility of CTCA+FFRCT to reduce pre-TAVR ICA and per-vessel diagnostic performance. Result(s): 327 patients (76 +/- 10 years, 53% men) underwent CTCA. CTCA was safe and well tolerated in nearly all patients, with self-limiting hypotension in 4 (1.2%). CTCA was evaluable in 326 patients (99.7%), with 9 (2.8%) having a non-evaluable vessel. Significant CAD was present in 150 patients (45.8%), with a median calcium score of 445 (108-1,035). FFRCT was requested in 125 (38.2%) patients of whom 110 (88.0%) were feasible for analysis. ICA was performed in 133 (40.7%) patients. Per-patient sensitivity, specificity, NPV, and PPV of CTCA were 100%, 71.4%, 100%, and 75.9% and per-vessel 82.7%, 78.9%, 92.3%, and 59.9%, respectively. FFRCT improved specificity and PPV to 88.9% and 88.0% for per-patient and 95.1% and 81.8% for per-vessel analysis. Based on observed reclassification rates from CTCA and FFRCT, 270 patients (82.6%) could potentially avoid ICA. Conclusion(s): CTCA when optimized with nitroglycerin and beta-blockers is safe, feasible, and effective for assessing CAD in select severe AS patients. Combining CTCA with FFRCT enhances diagnostic accuracy, potentially reducing the need for invasive coronary angiography and streamlining TAVR workup.Copyright © 2024