• CCTA
• TAVI

Background:
The prevalence of coronary artery disease (CAD) among patients with aortic valve stenosis is estimated to be approximately 50%, ascribed to a shared pathophysiological pathway involving atherosclerosis and the coexistence of multiple overlapping risk factors. For this reason, assessment of CAD in the context of transcatheter aortic valve implantation (TAVI) remains a topic of significant clinical interest. While invasive coronary angiography (ICA) remains the standard of care, coronary computed tomography angiography (CCTA) is increasingly being integrated into diagnostic workflows, thanks to its high sensitivity and negative predictive value. Nevertheless, the evidence regarding its safety and efficacy as a possible replacement for ICA in TAVI context remains limited. This study aims to evaluate the safety of a CCTA-based approach in patients undergoing TAVI.
Methods and Results:
Between 2017 and 2023, patients undergoing CCTA during TAVI diagnostic workflow were prospectively enrolled in a dedicated database. We further retrospective enrolled a cohort of patients undergoing ICA before TAVI from 2015 and 2023 in order to compare the two strategies. The primary endpoint was cardiovascular mortality at two year, while the secondary endpoint was a non-hierarchical composite of all-cause mortality, stroke, Valve Academic Research Consortium (VARC) 2–4 bleeding, acute coronary syndrome (ACS), and new revascularizations at two-year follow-up. A total of 1,218 patients were enrolled (median age 84 years [81–87], 57% female), 851 in the CCTA group and 377 in the ICA group. By means of propensity score matching we then selected 296 patients from the CCTA group and 296 patients from the ICA group, and compared the clinical outcomes between groups. CCTA was able to exclude “significant CAD” in 62% of patients in the study population, who did not undergo ICA. Median follow-up was 2.3[1.2-3.5] years. N+o statistically significant differences were observed in the primary endpoint between the two groups (89,1% in the ICA group vs. 5.4% in the CCTA group; log-rank test, p=0.087). The secondary endpoint occurred less frequently in the CCTA group compared to the ICA group (26% vs. 20.3%; log-rank test, p=0.03), driven by a lower incidence of all cause mortality (22,6% vs. 14,9%; p=0.02), while the rates of ACS , coronary revascularization and strokes were similar. Notably, early discharge (i.e. within 72 hours of TAVI) was twice more frequent in the CCTA group (59.8% vs 32.4%; p<0.001)
Conclusions:
A CCTA-based diagnostic approach appears to be safe and effective, reducing the number of invasive angiographic procedures and concurrently shortening the average hospital length of stay without compromising patient healthcare.