Coronary computed tomography angiography for heart team decision-making in multivessel coronary artery disease

Carlos Collet, Yoshinobu Onuma, Daniele Andreini, Jeroen Sonck, Giulio Pompilio, Saima Mushtaq, Mark La Meir, Yosuke Miyazaki, Johan de Mey, Oliver Gaemperli, Ahmed Ouda, Juan Pablo Maureira, Damien Mandry, Edoardo Camenzind, Laurent Macron, Torsten Doenst, Ulf Teichgräber, Holger Sigusch, Taku Asano, Yuki Katagiri, Marie-Angele Morel, Wietze Lindeboom, Gianluca Pontone, Thomas F Lüscher, Antonio L Bartorelli, Patrick W Serruys, Carlos Collet, Yoshinobu Onuma, Daniele Andreini, Jeroen Sonck, Giulio Pompilio, Saima Mushtaq, Mark La Meir, Yosuke Miyazaki, Johan de Mey, Oliver Gaemperli, Ahmed Ouda, Juan Pablo Maureira, Damien Mandry, Edoardo Camenzind, Laurent Macron, Torsten Doenst, Ulf Teichgräber, Holger Sigusch, Taku Asano, Yuki Katagiri, Marie-Angele Morel, Wietze Lindeboom, Gianluca Pontone, Thomas F Lüscher, Antonio L Bartorelli, Patrick W Serruys

Abstract

Aims: Coronary computed tomography angiography (CTA) has emerged as a non-invasive diagnostic method for patients with suspected coronary artery disease, but its usefulness in patients with complex coronary artery disease remains to be investigated. The present study sought to determine the agreement between separate heart teams on treatment decision-making based on either coronary CTA or conventional angiography.

Methods and results: Separate heart teams composed of an interventional cardiologist, a cardiac surgeon, and a radiologist were randomized to assess the coronary artery disease with either coronary CTA or conventional angiography in patients with de novo left main or three-vessel coronary artery disease. Each heart team, blinded for the other imaging modality, quantified the anatomical complexity using the SYNTAX score and integrated clinical information using the SYNTAX Score II to provide a treatment recommendations based on mortality prediction at 4 years: coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or equipoise between CABG and PCI. The primary endpoint was the agreement between heart teams on the revascularization strategy. The secondary endpoint was the impact of fractional flow reserve derived from coronary CTA (FFRCT) on treatment decision and procedural planning. Overall, 223 patients were included. A treatment recommendation of CABG was made in 28% of the cases with coronary CTA and in 26% with conventional angiography. The agreement concerning treatment decision between coronary CTA and conventional angiography was high (Cohen's kappa 0.82, 95% confidence interval 0.74-0.91). The heart teams agreed on the coronary segments to be revascularized in 80% of the cases. FFRCT was available for 869/1108 lesions (196/223 patients). Fractional flow reserve derived from coronary CTA changed the treatment decision in 7% of the patients.

Conclusion: In patients with left main or three-vessel coronary artery disease, a heart team treatment decision-making based on coronary CTA showed high agreement with the decision derived from conventional coronary angiography suggesting the potential feasibility of a treatment decision-making and planning based solely on this non-invasive imaging modality and clinical information.

Trial registration number: NCT02813473.

Figures

Figure 1
Figure 1
A flow chart of the study. FFRCT, fractional flow reserve derived from coronary computed tomography angiography.
Take home figure
Take home figure
Case example of the non-invasive and invasive assessment using the anatomical SYNTAX score and SYNTAX Score II. A 74-year-old man with a creatinine clearance 38 mL/min and left ventricular ejection fraction of 50% without history of chronic obstructive pulmonary disease or peripheral vascular disease. At the top, coronary computed tomography angiography shows three-vessel disease with a coronary narrowings located at the ostium and in the proximal segment of the right coronary artery; two narrowings located in the mid segment of the left anterior descending artery; and one additional narrowing in the proximal segment of the left circumflex artery involving the bifurcation with the first obtuse marginal coronary artery. Conventional angiography revealed also a three-vessel disease with one narrowing located at the proximal segment of the right coronary artery, one narrowing at the mid segment of the left anterior descending artery, and a bifurcation lesion involving the proximal segment of the left circumflex artery and the first obtuse marginal coronary artery. Each coronary narrowing was scored according to the anatomical SYNTAX score and the final anatomical SYNTAX score derived from each modality is shown. With both imaging modalities, the SYNTAX score II recommended either coronary artery bypass graft surgery or percutaneous coronary intervention based on a comparable predicted 4-year mortality. At the bottom, the non-invasive fractional flow reserve derived from coronary computed tomography angiography (FFRCT) is presented. The FFRCT showed that the lesions in the right coronary artery are not haemodynamically relevant, whereas the left anterior descending artery and left circumflex artery have haemodynamically relevant lesions. The treatment recommendation based on coronary computed tomography angiography with FFRCT remained equipoise between coronary artery bypass graft surgery and percutaneous coronary intervention but the treatment planning changed based on the negative FFRCT results in the right coronary artery. CABG, coronary artery bypass graft surgery; LAD, left anterior descending artery; LCX, left circumflex artery; PCI, percutaneous coronary intervention; RCA, right coronary artery.
Figure 2
Figure 2
Correlation and agreement on the anatomical SYNTAX score (A) and SYNTAX score II (B) between coronary computed tomography angiography and conventional angiography.
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/6241466/bin/ehy581f3.jpg

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