Study Backs Use of CTA to Screen Potential TAVR Candidates
Outcomes of TAVR are equivalent regardless of whether or not patients undergo coronary computed tomographic angiography (CTA) alone or in conjunction with invasive angiography, according to a study published online July 9, 2015, ahead of print in Circulation: Cardiovascular Interventions.
Given CTA’s potential to decrease costs and increase efficiency, researchers say, it stands out as a viable alternative to angiography as a pre-TAVR screening tool.
Alaide Chieffo, MD, of San Raffaele Scientific Institute (Milan, Italy), and colleagues retrospectively analyzed data of 491 patients (mean age 79.7 years; 48.7% men) who underwent TAVR at a single center between 2007 and 2013. Patients were grouped by whether they received CTA with (n = 116) or without (n = 375) invasive coronary angiography before TAVR.
Baseline characteristics were well balanced between the 2 arms, except that patients who received CTA alone had a higher rate of chronic kidney disease and a lower incidence of previous PCI, CAD, and porcelain aorta compared with those who also had invasive angiography. There were no differences in procedural data.
Similar Safety, Efficacy
Postprocedural aortic regurgitation and device malposition contributed to a decreased device success rate for patients who received additional invasive angiography compared with the CTA alone group (65.5% vs 75.2%; P = .04).
At both 30 days and 1 year, all patients had comparable adjusted risks of MACCE (combined all-cause death, MI, ischemia-driven revascularization, and cerebrovascular events). Similarly, there were no differences between groups for Valve Academic Research Consortium-2–defined all-cause mortality, cardiovascular mortality, short-term safety, and long-term clinical efficacy (table 1).
Additionally, those who received CTA alone experienced shorter hospital lengths of stay than those who also had conventional angiography (9 vs 10 days; P = .04).
A Move Toward ‘Minimalist TAVR’
“Even if associated hospital costs were not captured in our study, the avoidance of invasive [coronary angiography] and shorter in-hospital stay might allow a significant saving on the overall TAVR costs,” Dr. Chieffo and colleagues write. “Performing [angiography] only when absolutely necessary,” they add, “could lead to improved outcomes [as well as] reductions in the overall procedural cost and hospitalization time.”
Advocating for the concept of “minimalist TAVR,” Danny Dvir, MD, of St. Paul’s Hospital (Vancouver, Canada), writes in an accompanying editorial: “In this new era of high-volume TAVR procedures and long waiting lists, there is a need for a more efficient system for patient assessment.”
Dr. Dvir remarks that the avoidance of invasive screening is an advantage, especially for patients with severe aortic stenosis, who “are commonly frail and… have multiple comorbidities.” Moreover, CTA removes the potential for additional “injury to the same vessel intended to be used later during [TAVR]” and decreases the length of hospital stay, he notes.
Yet Dr. Dvir cautions that the results of this single-center study may not be generalizable to patients treated elsewhere.
Additionally, conventional angiography does provide the opportunity “to perform a PCI at the same time of TAVR,” he notes. In that context, it may also lower the costs associated with “multiple hospitalizations and invasive procedures.”
And while safety was not compromised in the CTA cohort, invasive coronary angiography remains the standard method “for patients in whom [coronary CTA] is contraindicated [or] failed to assess coronary anatomy or when a significant proximal coronary artery lesion is detected at [CTA],” the authors say.
While “time will tell” which strategy is best suited to evaluating patients with severe aortic stenosis, the evidence now points to “patient-tailored” care, Dr. Dvir concludes. “A minimalist approach includes several advantages, [but] cardiologists must continue working closely with radiologists to further test the safety of bypassing cath-laboratory assessment in candidates for TAVR.”
1. Chieffo A, Giustino G, Spagnolo P, et al. Routine screening of coronary artery disease with computed tomographic coronary angiography in place of invasive coronary angiography in patients undergoing transcatheter aortic valve replacement. Circ Cardiovasc Interv. 2015;Epub ahead of print.
2. Dvir, D. Minimalist approach to evaluating patients for transcatheter aortic valve replacement [editorial]. Circ Cardiovasc Interv. 2015;Epub ahead of print.
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*Nicole Lou is the 2015 Recipient of the Jason Kahn Fellowship in Medical Journalism
- Dr. Chieffo reports no relevant conflicts of interest.
- Dr. Dvir reports serving as a consultant for Edwards Lifesciences and Medtronic.