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

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

Feasibility of planning coronary artery bypass grafting based only on coronary computed tomography angiography and CT-derived fractional flow reserve : a pilot survey of the surgeons involved in the randomized SYNTAX III Revolution trial

Invasive coronary angiography has been the preferred diagnostic method to guide the decision-making process between coronary artery bypass grafting (CABG) and percutaneous coronary intervention and plan a surgical revascularization procedure. Guidelines recommend a heart team approach and assessment of coronary artery disease (CAD) complexity, objectively quantified by the anatomical SYNTAX score. Coronary computed tomography angiography (CCTA) and CT-derived fractional flow reserve (FFRCT) are emerging technologies in the diagnosis of stable CAD. In this study, data from patients with left main or 3-vessel CAD who underwent CABG were evaluated to assess the feasibility of developing a surgical plan based on CCTA integrated with FFRCT. The primary objective was to assess the theoretical feasibility of surgical decision-making and treatment planning based only on non-invasive imaging