Feasibility and Comparison of Resting Full-Cycle Ratio and Computed Tomography Fractional Flow Reserve in Patients with Severe Aortic Valve Stenosis

Wienemann, Hendrik; Langenbach, M; Mauri, Victor; Banazadeh, Maryam; Klein, Konstantin; Hohmann, Christopher; Lee, Samuel; Breidert, Isabel; Hof, Alexander; Eghbalzadeh, Kaveh; Kuhn, Elmar; Halbach, Marcel; Maintz, David; Baldus, Stephan; Bunck, Alexander C.; Adam, Matti

doi:10.3390/jcdd9040116

Cited by 3 publications

(1 citation statement)

References 42 publications

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“…Dies ist ebenfalls gut mit der CT möglich. Die CT-basierte Messung der fraktionellen Flussreserve (CT-FFR) hilft zur Bestimmung hämodynamisch relevanter intermediärer Stenosen 18 , 19 .…”

Section: Aortenklappenstenoseunclassified

Präinterventionelle Klappenbildgebung in der CT: TAVR, TMVR und mehr

Langenbach¹,

Foldyna²,

Maintz³

et al. 2023

Radiologie up2date

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ZusammenfassungKlappenerkrankungen zählen zu den häufigsten Herzerkrankungen, werden häufiger und können immer besser behandelt werden. Zwar benötigt nicht jede Klappenerkrankung zwingend eine radiologische Bildgebung, doch insbesondere für die Aorten- und Mitralklappe spielt die radiologische Beurteilung eine wichtige Rolle. In diesem Beitrag steht vor allem die CT vor Klappeneingriffen im Vordergrund.

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Section: Aortenklappenstenoseunclassified

Präinterventionelle Klappenbildgebung in der CT: TAVR, TMVR und mehr

Langenbach¹,

Foldyna²,

Maintz³

et al. 2023

Radiologie up2date

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Reduction of contrast medium for transcatheter aortic valve replacement planning using a spectral detector CT: a prospective clinical trial

Langenbach,

Mayrhofer

et al. 2023

Eur Radiol

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Introduction This study investigated the use of dual-energy spectral detector computed tomography (CT) and virtual monoenergetic imaging (VMI) reconstructions in pre-interventional transcatheter aortic valve replacement (TAVR) planning. We aimed to determine the minimum required contrast medium (CM) amount to maintain diagnostic CT imaging quality for TAVR planning. Methods In this prospective clinical trial, TAVR candidates received a standardized dual-layer spectral detector CT protocol. The CM amount (Iohexol 350 mg iodine/mL, standardized flow rate 3 mL/s) was reduced systematically after 15 patients by 10 mL, starting at 60 mL (institutional standard). We evaluated standard, and 40- and 60-keV VMI reconstructions. For image quality, we measured signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and diameters in multiple vessel sections (i.e., aortic annulus: diameter, perimeter, area; aorta/arteries: minimal diameter). Mixed regression models (MRM), including interaction terms and clinical characteristics, were used for comparison. Results Sixty consecutive patients (mean age, 79.4 ± 7.5 years; 28 females, 46.7%) were included. In pre-TAVR CT, the CM reduction to 40 mL is possible without affecting the image quality (MRM: SNR: –1.1, p = 0.726; CNR: 0.0, p = 0.999). VMI 40-keV reconstructions showed better results than standard reconstructions with significantly higher SNR (+ 6.04, p < 0.001). Reduction to 30 mL CM resulted in a significant loss of quality (MRM: SNR: –12.9, p < 0.001; CNR: –13.9, p < 0.001), regardless of the reconstruction. Across the reconstructions, we observed no differences in the metric evaluation (p > 0.914). Conclusion Among TAVR candidates undergoing pre-interventional CT at a dual-layer spectral detector system, applying 40 mL CM is sufficient to maintain diagnostic image quality. VMI 40-keV reconstructions improve the vessel attenuation and are recommended for evaluation. Clinical relevance statement Contrast medium reduction to 40 mL in pre-interventional transcatheter aortic valve replacement CT using dual-energy CT maintains image quality, while 40-keV virtual monoenergetic imaging reconstructions enhance vessel attenuation. These results offer valuable recommendations for interventional transcatheter aortic valve replacement evaluation and potentially improve nephroprotection in patients with compromised renal function. Key Points • Patients undergoing transcatheter aortic valve replacement (TAVR), requiring pre-interventional CT, are often multimorbid with impaired renal function. • Using a spectral detector dual-layer CT, contrast medium reduction to 40 mL is feasible, maintaining diagnostic image quality. • The additional application of virtual monoenergetic image reconstructions with 40 keV improves vessel attenuation significantly in clinical practice.

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

Langenbach,

Foldyna

et al. 2024

Eur Radiol

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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.

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Feasibility and Comparison of Resting Full-Cycle Ratio and Computed Tomography Fractional Flow Reserve in Patients with Severe Aortic Valve Stenosis

Cited by 3 publications

References 42 publications

Präinterventionelle Klappenbildgebung in der CT: TAVR, TMVR und mehr

Präinterventionelle Klappenbildgebung in der CT: TAVR, TMVR und mehr

Reduction of contrast medium for transcatheter aortic valve replacement planning using a spectral detector CT: a prospective clinical trial

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

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