TAVR-CTA May Replace Invasive Angiography in Select Pre-TAVR CAD Cases

Preprocedural coronary artery disease (CAD) assessment remains a key component of planning transcatheter aortic valve replacement (TAVR). Invasive coronary angiography (ICA) has been the traditional standard but may delay procedures and expose patients to procedural risks. Dr. Phichaphop, and their colleagues report findings from a pragmatic, single-center study evaluating whether coronary computed tomography angiography (CTA), performed as part of routine pre-TAVR imaging without premedication, can serve as a safe and effective alternative to ICA.

The study included 1,165 patients undergoing TAVR at a U.S. tertiary care center from 2017 to 2022. Patients with prior coronary artery bypass grafting were excluded. Participants were stratified based on the initial CAD evaluation strategy: 464 underwent CTA-first screening (TAVR-CTA group), and 701 received routine ICA. The primary endpoint was symptom-driven coronary revascularization at one-year post-TAVR. The secondary endpoint was the proportion of patients who avoided ICA after TAVR-CTA assessment.

In the TAVR-CTA group, 53% of patients were exempted from ICA based on non-obstructive CTA findings. Among those requiring ICA after CTA, 17% had inconclusive imaging, 15% underwent ICA despite negative CTA per operator discretion, and 14% had suspected obstructive CAD. CTA demonstrated a sensitivity of 89%, specificity of 75%, a positive predictive value of 69%, and a negative predictive value of 91% for detecting proximal obstructive CAD.

At one-year follow-up, clinical outcomes were comparable between groups. Symptom-driven revascularization occurred in 0.8% of CTA-screened patients versus 1.8% of those undergoing routine ICA (P=0.158). Rates of ACS (1.6% vs 1.7%, P=0.846) and unplanned ICA (2.7% vs 2.8%, P=0.767) were similarly low and not statistically different. Importantly, the ratio of PCI to ICA was higher in the CTA group (0.29 vs 0.19, P=0.003), suggesting more selective and efficient downstream use of invasive procedures.

The use of CTA as a gatekeeper allowed safe avoidance of ICA in over half of the patients, without increasing short-term coronary events. Elevated coronary calcium scores and prior stenting were predictive of requiring ICA despite initial CTA.

These results support TAVR-CTA without pre-medication as a practical and effective tool for CAD triage in the pre-TAVR setting. Adopting this strategy may reduce procedural burden and expedite TAVR access, especially in patients with a low likelihood of significant proximal CAD. Broader validation in multicenter settings may help refine the role of CTA in contemporary TAVR workflows.