J Cardiovasc Comput Tomogr. 2026 Jan 20:S1934-5925(25)00599-4. doi: 10.1016/j.jcct.2025.12.012. Online ahead of print.
ABSTRACT
BACKGROUND: Coronary artery disease (CAD) is common in patients with severe aortic stenosis (AS) and may impact transcatheter aortic valve replacement (TAVR) procedural and long-term outcomes. CT coronary angiography (CTA) and CT-derived fractional flow reserve (FFRCT) are tools used to assess CAD. However, adoption in the TAVR population is hindered by safety concerns with nitroglycerin and beta-blockers. The safety, accuracy, and utility of CTA and FFRCT optimised with these medications for TAVR have not been established.
METHODS: This international, multi-center, prospective registry included severe AS patients referred for TAVR, assessed for CAD with CTA and FFRCT. Patients all received nitroglycerin and beta-blockers as needed to optimise image quality. Severe ventricular dysfunction, recent syncope/heart failure, critical hemodynamics, or prior revascularization were excluded. Significant CAD was defined as CTA stenosis ≥50 % and FFRCT≤0.75. Primary endpoint was per-patient sensitivity and negative predictive value (NPV) of CTA compared to invasive coronary angiography (ICA). Secondary endpoints included specificity and positive predictive value (PPV) of CTA and FFRCT, safety, feasibility (non-evaluable rate), and the modelled potential of CTA + FFRCT to reduce pre-TAVR ICA.
RESULTS: 327 patients (75.9 ± 9.7 years, 53 % male) underwent CTA. CTA was safe and well tolerated in nearly all patients, with transient hypotension in 4 (1.2 %). CTA was evaluable in 326 patients (99.7 %), with 9 (2.8 %) having a non-evaluable vessel. FFRCT and ICA were performed in 110 (33.6 %) and 133 (40.7 %) patients, respectively. Per-patient sensitivity, specificity, NPV, and PPV of CTA were 100 %, 71.4 %, 100 %, and 75.9 % and per-vessel 82.7 %, 78.9 %, 92.3 %, and 59.9 %. FFRCT improved specificity and PPV to 88.9 % and 88.0 % for per-patient and 95.1 % and 81.8 % for per-vessel analysis. Using a simulated triage model deferring ICA in patients with CTA <50 % or ≥50 % stenosis with FFRCT >0.75, 267 patients (81.7 %) could potentially have avoided ICA.
CONCLUSION: Coronary CTA performed with nitroglycerin and selective use of beta-blockers is safe and effective for assessing CAD in stable severe AS patients. Combining CTA and FFRCT enhances diagnostic accuracy, potentially reducing the need for invasive angiography and streamlining TAVR workup.
PMID:41565522 | DOI:10.1016/j.jcct.2025.12.012