Diagnostic accuracy of computed tomography angiography for the exclusion of coronary artery disease in candidates for transcatheter aortic valve implantation
Diagnostic accuracy of computed tomography angiography for the exclusion of coronary artery disease in candidates for transcatheter aortic valve implantation
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DOI：
10.1038/s41598-019-56519-3
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发表时间：
2019-12-27
影响因子：
4.6
通讯作者：
Mendes, Miguel
中科院分区：
文献类型：
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作者：
Strong, Christopher;Ferreira, Antonio;Mendes, Miguel
冠状动脉CT血管成像(CTA)目前被认为是心脏瓣膜手术前预测概率低的患者排除阻塞性冠状动脉疾病(CAD)的可靠方法。然而，在经导管主动脉瓣置入术(TAVI)前，它在排除梗阻性CAD中的作用还不是很清楚。作为TAVI计划的一部分，对有严重症状性主动脉狭窄的患者同时进行CTA和有创冠状动脉造影术(ICA)的单中心回顾性研究。CTA检查在双源扫描仪上进行，平均间隔45天(IQR25-75[13-82])。在这两项试验中，梗阻性CAD定义为心外膜血管直径=2 mm的狭窄程度为50%。按患者、按血管和按近端节段进行分析，排除和包括不可评估的节段。这项研究包括200名患者(120名女性，平均年龄83±6岁)。ICA梗阻性冠状动脉病变的发生率为35.5%(n=71)。在每名患者的分析中(假设不可评估的节段为狭窄)，CTA的敏感性为100%(95%CI，95-100%)，特异性为42%(95%CI，33-51%)，阳性预测值和阴性预测值分别为48%(95%CI，44-51%)和100%(95%CI，92-100%)。在54例(27%)患者中，CTA能够排除阻塞性CAD，而ICA本可以安全地保留。尽管不确定测试的比率很高，但在接受TAVI治疗的患者中，术前CTA能够安全地排除梗阻性CAD，可能在大约四分之一的病例中避免需要ICA。
Coronary CT angiography (CTA) is currently considered a reliable method to exclude obstructive coronary artery disease (CAD) before valvular heart surgery in patients with low pretest probability. However, its role in excluding obstructive CAD before transcatheter aortic valve implantation (TAVI) is less well established. Single-center retrospective study where patients with severe symptomatic aortic stenosis underwent both CTA and invasive coronary angiography (ICA) as part of TAVI planning. CTA exams were conducted on a 64-slice dual source scanner, with a median interval of 45 days to ICA (IQR 25-75 [13-82]). In both tests, obstructive CAD was defined as a >= 50% stenosis in an epicardial vessel >= 2 mm diameter. Per-patient, per-vessel and per-proximal segment analyses were conducted, excluding and including non-evaluable segments. The study included 200 patients (120 women, mean age 83 +/- 6 years). The prevalence of obstructive CAD on ICA was 35.5% (n = 71). On a per-patient analysis (assuming non-evaluable segments as stenotic), CTA showed sensitivity of 100% (95% CI, 95-100%), specificity of 42% (95% CI, 33-51%), and positive and negative predictive values of 48% (95% CI, 44-51%) and 100% (95% CI, 92-100%), respectively. CTA was able to exclude obstructive CAD in 54 patients (27%), in whom ICA could have been safely withheld. Despite the high rate of inconclusive tests, pre-procedural CTA is able to safely exclude obstructive CAD in a significant proportion of patients undergoing TAVI, possibly avoiding the need for ICA in roughly one quarter of the cases.