Advanced CT measures of coronary artery disease with intermediate stenosis in patients with severe aortic valve stenosis

Marcel C Langenbach; Isabel L Langenbach; Borek Foldyna; Victor Mauri; Konstantin Klein; Sascha Macherey-Meyer; Sebastian Heyne; Max Meertens; Samuel Lee; Stephan Baldus; David Maintz; Marcel Halbach; Matti Adam; Hendrik Wienemann

doi:10.1007/s00330-023-10549-8

Advanced CT measures of coronary artery disease with intermediate stenosis in patients with severe aortic valve stenosis

Eur Radiol. 2024 Jan 8. doi: 10.1007/s00330-023-10549-8. Online ahead of print.

Authors

Marcel C Langenbach^{1

2}, Isabel L Langenbach^{3

4}, Borek Foldyna⁴, Victor Mauri⁵, Konstantin Klein³, Sascha Macherey-Meyer⁵, Sebastian Heyne⁵, Max Meertens⁵, Samuel Lee⁵, Stephan Baldus⁵, David Maintz³, Marcel Halbach⁵, Matti Adam⁵, Hendrik Wienemann⁵

Affiliations

¹ Faculty of Medicine and University Hospital Cologne, Institute for Diagnostic and Interventional Radiology, University of Cologne, Kerpener Strasse 62, Cologne, 50937, Germany. mlangenbach@mgh.harvard.edu.
² Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA. mlangenbach@mgh.harvard.edu.
³ Faculty of Medicine and University Hospital Cologne, Institute for Diagnostic and Interventional Radiology, University of Cologne, Kerpener Strasse 62, Cologne, 50937, Germany.
⁴ Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA.
⁵ Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany.

PMID: 38189982
DOI: 10.1007/s00330-023-10549-8

Abstract

Background: Coronary artery disease (CAD) and severe aortic valve stenosis (AS) frequently coexist. While pre-transcatheter aortic valve replacement (TAVR) computed tomography angiography (CTA) allows to rule out obstructive CAD, interpreting hemodynamic significance of intermediate stenoses is challenging. This study investigates the incremental value of CT-derived fractional flow reserve (CT-FFR), quantitative coronary plaque characteristics (e.g., stenosis degree, plaque volume, and composition), and peri-coronary adipose tissue (PCAT) density to detect hemodynamically significant lesions among those with AS and CAD.

Materials and methods: We included patients with severe AS and intermediate coronary lesions (20-80% diameter stenosis) who underwent pre-TAVR CTA and invasive coronary angiogram (ICA) with resting full-cycle ratio (RFR) assessment between 08/16 and 04/22. CTA image analysis included assessment of CT-FFR, quantitative coronary plaque analysis, and PCAT density. Coronary lesions with RFR ≤ 0.89 indicated hemodynamic significance as reference standard.

Results: Overall, 87 patients (age 77.9 ± 7.4 years, 38% female) with 95 intermediate coronary artery lesions were included. CT-FFR showed good discriminatory capacity (area under receiver operator curve (AUC) = 0.89, 95% confidence interval (CI) 0.81-0.96, p < 0.001) to identify hemodynamically significant lesions, superior to anatomical assessment, plaque morphology, and PCAT density. Plaque composition and PCAT density did not differ between lesions with and without hemodynamic significance. Univariable and multivariable analyses revealed CT-FFR as the only predictor for functionally significant lesions (odds ratio 1.28 (95% CI 1.17-1.43), p < 0.001). Overall, CT-FFR ≤ 0.80 showed diagnostic accuracy, sensitivity, and specificity of 88.4% (95%CI 80.2-94.1), 78.5% (95%CI 63.2-89.7), and 96.2% (95%CI 87.0-99.5), respectively.

Conclusion: CT-FFR was superior to CT anatomical, plaque morphology, and PCAT assessment to detect functionally significant stenoses in patients with severe AS.

Clinical relevance statement: CT-derived fractional flow reserve in patients with severe aortic valve stenosis may be a useful tool for non-invasive hemodynamic assessment of intermediate coronary lesions, while CT anatomical, plaque morphology, and peri-coronary adipose tissue assessment have no incremental or additional benefit. These findings might help to reduce pre-transcatheter aortic valve replacement invasive coronary angiogram.

Key points: • Interpreting the hemodynamic significance of intermediate coronary stenoses is challenging in pre-transcatheter aortic valve replacement CT. • CT-derived fractional flow reserve (CT-FFR) has a good discriminatory capacity in the identification of hemodynamically significant coronary lesions. • CT-derived anatomical, plaque morphology, and peri-coronary adipose tissue assessment did not improve the diagnostic capability of CT-FFR in the hemodynamic assessment of intermediate coronary stenoses.

Keywords: Aortic valve stenosis; Coronary angiography; Coronary artery disease; Fractional flow reserve (myocardial); Tomography (X-ray computed).