Agatston scoring for assessment of coronary artery disease in patients undergoing transcatheter aortic valve implantation.

Computed tomography (CT) angiography remains a cornerstone of pre-interventional assessment for transaortic valve implantation (TAVI). CT imaging prior to TAVI further allows for evaluation of the coronary arteries, with the simplest method being the calculation of the coronary Agatston score. Following the expansion of TAVI to lower risk patients, non-invasive coronary diagnostics in the framework of TAVI gain importance as they may allow patients to avoid unnecessary invasive coronary angiography (ICA) before the procedure. This study evaluates the diagnostic performance of coronary Agatston score values on pre-TAVI CT scans for the assessment of coronary artery disease. A total of 285 patients received a standard TAVI evaluation CT scan and routine ICA prior to the TAVI procedure. Agatston score values of the coronary tree and the proximal coronary segments (1, 5, 6, 11) were calculated separately by two radiologists. Reference for the AUC analysis was performance of PCI or stenting of the corresponding coronary segment following the recommendation of the Heart Team. ROC-analysis was performed for evaluation of the Agatston score at the level of the heart, the coronary arteries and the proximal coronary vessel segments (1, 5, 6 and 11) level to determine cutoff-values for optimal sensitivity and specificity. A total of 285 patients received a standard TAVI evaluation CT scan and routine ICA prior to the TAVI procedure. Agatston score values of the coronary tree and the proximal coronary segments (1, 5, 6, 11) were calculated separately by two radiologists. Reference for the AUC analysis was performance of PCI or stenting of the corresponding coronary segment following the recommendation of the Heart Team. ROC-analysis was performed for evaluation of the Agatston score at the level of the heart, the coronary arteries and the proximal coronary vessel segments (1, 5, 6 and 11) level to determine cutoff-values for optimal sensitivity and specificity. Coronary artery disease requiring intervention was present in 61 patients upon ICA (17.9%). In predicting the need of performance of a coronary intervention at a sensitivity of >89%, Agatston values of the full coronary tree >170 allow for a sensitivity of 90% (AUC 0.76, NPV 0.93). The sum Agatston score of the proximal segments >117 enables a sensitivity of 90% (AUC 0.74, NPV 0.93) and >47 a sensitivity of 98% (NPV 0.98). On the segmental level, Agatston values of >22 in the proximal RCA and >30 in the proximal LAD and CX allow for a sensitivity of 90% (AUC RCA 0.74, NPV 0.98; LAD 0.71, NPV 0.94; CX 0.75, NPV 0.99). Aiming for 98% sensitivity or higher, Agatston values of >2 for the RCA, >3 for the LAD and >27 for the CX apply (RCA NPV 1; LAD NPV 0.97; CX NPV 1). Coronary artery Agatston scoring on TAVI evaluation CT scans can serve as a predictor for the need of coronary interventions in the workup leading up to TAVI and it provides valuable information for identification of patients without significant coronary artery disease and may aid in allowing for the avoidance of invasive coronary artery diagnostics.