使用CTA检测经导管主动脉瓣植入术前检查中的近端冠状动脉狭窄（来自DEPICT CTA合作项目）
DEtection of ProxImal Coronary stenosis in the work-up for Transcatheter aortic valve implantation using CTA (from the DEPICT CTA collaboration).
作者信息
van den Boogert Thomas P W, Claessen Bimmer E P M, Opolski Maksymilian P, Kim Won-Keun, Hamdan Ashraf, Andreini Daniele, Pugliese Francesca, Möllmann Helge, Delewi Ronak, Baan Jan, Vis M Marije, van Randen Adrienne, van Schuppen Joost, Stoker Jaap, Henriques José P, Planken R Nils
机构信息
Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands.
出版信息
Eur Radiol. 2022 Jan;32(1):143-151. doi: 10.1007/s00330-021-08095-2. Epub 2021 Jun 16.
OBJECTIVES
Computed tomography angiography (CTA) is performed routinely in the work-up for transcatheter aortic valve implantation (TAVI), and could potentially replace invasive coronary angiography (ICA) to rule out left main (LM) and proximal coronary stenosis. The objectives were to assess the diagnostic yield and accuracy of pre-TAVI CTA to detect LM and proximal coronary stenosis of ≥ 50% and ≥ 70% diameter stenosis (DS).
METHODS
The DEPICT CTA database consists of individual patient data from four studies with a retrospective design that analyzed the diagnostic accuracy of pre-TAVI CTA to detect coronary stenosis, as compared with ICA. Pooled data were used to assess diagnostic accuracy to detect coronary stenosis in the left main and the three proximal coronary segments on a per-patient and a per-segment level. We included 1060 patients (mean age: 81.5 years, 42.7% male).
RESULTS
On ICA, the prevalence of proximal stenosis was 29.0% (≥ 50% DS) and 15.7% (≥ 70% DS). Pre-TAVI CTA ruled out ≥ 50% DS in 51.6% of patients with a sensitivity of 96.4%, specificity of 71.2%, PPV of 57.7%, and NPV of 98.0%. For ≥ 70% DS, pre-TAVI CTA ruled out stenosis in 70.0% of patients with a sensitivity of 96.7%, specificity of 87.5%, PPV of 66.9%, and NPV of 99.0%.
CONCLUSION
CTA provides high diagnostic accuracy to rule out LM and proximal coronary stenosis in patients undergoing work-up for TAVI. Clinical application of CTA as a gatekeeper for ICA would reduce the need for ICA in 52% or 70% of patients, using a threshold of ≥ 50% or ≥ 70% DS, respectively.
KEY POINTS
• Clinical application of CTA as a gatekeeper for ICA would reduce the need for ICA in 52% or 70% of TAVI patients, using a threshold of ≥ 50% or ≥ 70% diameter stenosis. • The diagnostic accuracy of CTA to exclude proximal coronary stenosis in these patients is high, with a sensitivity of 96.4% and NPV of 98.0% for a threshold of ≥ 50%, and a sensitivity of 96.7% and NPV of 99.0% for a threshold of ≥ 70% diameter stenosis. • Atrial fibrillation and heart rate did not significantly affect sensitivity and NPV. However, a heart rate of < 70 b/min during CTA was associated with a significantly improved specificity and PPV.
目的
计算机断层扫描血管造影（CTA）在经导管主动脉瓣植入术（TAVI）的检查中常规进行，并且有可能取代有创冠状动脉造影（ICA）以排除左主干（LM）和近端冠状动脉狭窄。目的是评估TAVI术前CTA检测直径狭窄（DS）≥50%和≥70%的LM和近端冠状动脉狭窄的诊断率及准确性。
方法
DEPICT CTA数据库包含来自四项回顾性研究的个体患者数据，这些研究分析了TAVI术前CTA与ICA相比检测冠状动脉狭窄的诊断准确性。汇总数据用于评估在每位患者和每个节段水平上检测左主干和三个近端冠状动脉节段冠状动脉狭窄的诊断准确性。我们纳入了1060例患者（平均年龄：81.5岁，42.7%为男性）。
结果
在ICA检查中，近端狭窄的患病率为29.0%（DS≥50%）和15.7%（DS≥70%）。TAVI术前CTA在51.6%的患者中排除了DS≥50%，敏感性为96.4%，特异性为71.2%，阳性预测值为57.7%，阴性预测值为98.0%。对于DS≥70%，TAVI术前CTA在70.0%的患者中排除了狭窄，敏感性为96.7%，特异性为87.5%，阳性预测值为66.9%，阴性预测值为99.0%。
结论
CTA在TAVI检查患者中排除LM和近端冠状动脉狭窄具有较高的诊断准确性。将CTA作为ICA的把关检查的临床应用，分别使用≥50%或≥70% DS的阈值，将减少52%或70%患者对ICA的需求。
关键点
• 将CTA作为ICA的把关检查的临床应用，分别使用≥50%或≥70%直径狭窄的阈值，将减少52%或70%的TAVI患者对ICA的需求。• CTA排除这些患者近端冠状动脉狭窄的诊断准确性较高，对于≥50%的阈值，敏感性为96.4%，阴性预测值为98.0%；对于≥70%直径狭窄阈值，敏感性为96.7%，阴性预测值为99.0%。• 心房颤动和心率对敏感性和阴性预测值没有显著影响。然而，CTA期间心率<70次/分钟与特异性和阳性预测值显著提高相关。
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