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Coronary CTA for Heart Team Decision-Making in Multivessel CAD
Study Questions:
What is the agreement between separate heart teams on treatment decision-making based on either coronary computed tomography angiography (CTA) or conventional angiography?
Methods:
The SYNTAX III REVOLUTION investigators randomized separate heart teams composed of an interventional cardiologist, a cardiac surgeon, and a radiologist to assess the coronary artery disease (CAD) with either coronary CTA or conventional angiography in patients with de novo left main or three-vessel CAD. 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 recommendation 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. The agreement on the SYNTAX score between the two imaging modalities was assessed by the Bland–Altman and Passing Bablok method.
Results:
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 869/1,108 lesions (196/223 patients). Fractional flow reserve derived from coronary CTA changed the treatment decision in 7% of the patients.
Conclusions:
The authors concluded that in patients with left main or three-vessel CAD, a heart team treatment decision-making based on coronary CTA showed high agreement with the decision derived from conventional coronary angiography.
Perspective:
This study reports that treatment decision-making based on coronary CTA is in an almost perfect agreement with the decision derived from conventional coronary angiography in patients with left main or three-vessel CAD. The anatomical SYNTAX scores derived either from coronary CTA or conventional angiography showed a moderate degree of correlation, but the SYNTAX Score II demonstrated a high degree of correlation between the two diagnostic strategies. Furthermore, the concordance on the revascularization strategy between coronary CTA and conventional angiography reached approximately 80%. If confirmed in additional larger real-world studies, treatment decision-making based solely on coronary CTA and clinical information would be a viable future option obviating the need for invasive angiography in some patients.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging
Keywords: Cardiac Surgical Procedures, Coronary Angiography, Coronary Artery Bypass, Coronary Artery Disease, Diagnostic Imaging, Fractional Flow Reserve, Myocardial, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Radiology, Secondary Prevention, Tomography, X-Ray Computed
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