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Aims: Concomitant coronary artery disease (CAD) is frequent in transcatheter aortic valve implantation (TAVI) candidates. Despite societal recommendations of performing invasive coronary angiography (ICA) for coronary assessment in the pre-TAVI diagnostic workup, the prognostic value of ICA and beneficial effect of revascularization in these patients remains unclear. We aimed to determine feasibility and outcomes following a strategy of cardiac CT + coronary CT angiography (cCTA) rather than cardiac CT + ICA before TAVI., Methods and Results: We performed a single-center, observational cohort study including all patients, without previous coronary intervention, referred to TAVI between April 2020 and November 2021. CAD was assessed by cCTA, and only patients with proximal stenosis >70 %, or left main stenosis >50 %, or cCTA was non-evaluable regarding proximal segments were subsequently referred to ICA. 240 patients were included in the study. No adverse effects to pre-cCTA-scan nitroglycerin administration were observed. On cCTA, 92 % of the patients had atheroscerosis. 191 (80 %) patients had cCTA only performed, while 49 (20 %) patients underwent subsequent ICA. During a median (range) follow-up of 15 (Abdel-Wahab et al., 2012; Rapp et al., 2001; Sabbah et al., 2021; Gautier et al., 2011; Sankaramangalam et al., 2017; Otto et al., 2021; Tarantini et al., 2023; Vahanian et al., 2021; Faroux et al., 2019; Ferraro et al., 2020; Patterson et al., 2021; Blanke et al., 2019; Bleakley and Monaghan, 2018; Knuuti et al., 2020; Moss et al., 2017; van den Boogert et al., 2018; Collet et al., 2018; Linde et al., 2020; Schmidt et al., 2018; Hansson et al., 2013 [6-25]) months, no difference in procedural complication rates, mortality rates, or number of unplanned ICA was observed between patients evaluated with only cCTA vs cCTA+ICA., Conclusions: Upfront cCTA instead of ICA for assessment of obstructive CAD in the diagnostic workup of patients with severe aortic stenosis referred to TAVI is feasible, safe, and with similar procedural and clinical outcomes. Randomized studies are warranted to further validate the safety of using CTA rather than ICA for coronary assessment in TAVI candidates., Competing Interests: Declaration of competing interest Nothing to Disclose., (Copyright © 2024. Published by Elsevier B.V.)

Background: Coronary computed tomography angiography (CCTA) enables detailed quantification and characterization of coronary atherosclerotic plaques, offering diagnostic and prognostic value. Interscan reproducibility studies on plaque volume measurements are limited. This study aims to assess the interscan reproducibility of coronary plaque quantification and the implications of clinical and technical characteristics on interscan reproducibility., Methods: CCTA was performed twice in 101 patients with known coronary artery disease at a 1-h interval. The scans were conducted using identical CCTA acquisition protocols. Coronary plaque volumes were quantified using a semi-automated software and performed on a per-lesion, per-vessel, and per-patient level., Results: Median plaque volumes were comparable between the first and second CCTA scan. Interscan correlation was high for total plaque (TP), non-calcified plaque (NCP), and calcified plaque (CP) across all analyses (Pearson's coefficient 0.93-0.99), but lower for low-density non-calcified plaque (LD-NCP) volume measurements (Pearson's coefficient 0.74-0.77). Bland-Altman analyses demonstrated higher interscan agreement on a per-patient level compared to on per-vessel and per-lesion level. Interscan reproducibility on CP volumes was affected by CT image quality with narrower LoA in scans with the highest image quality score (p ​= ​0.003), or lowest image reconstructive iteration level (p ​< ​0.001). Limits of agreement were significantly narrower for TP, NCP, and CP volumes in LAD-lesions and vessels compared to non-LAD lesions and vessels (p ​≤ ​0.001)., Conclusion: Overall reproducibility of repeated CCTA derived plaque measurements by a semi-automated software was modest, and was influenced by image quality, image reconstruction settings, and lesion location., Competing Interests: Declaration of competing interest Bjarne L. Nørgaard has received unrestricted research grants from the Novo Nordic Research Foundation. Damini Dey received software royalties from Cedars-Sinai Medical Center and has a patent. Damini Dey is funded by National Heart, Lung, and Blood Institute, USA (1R01HL148787–01A1 and R01HL151266). The remaining authors had no disclosures to declare., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The prognostic impact of complete coronary revascularization relative to non-invasive testing methods is unknown., Objectives: To assess the association between completeness of revascularization defined by CTA-derived fractional flow reserve (FFR CT ) and cardiovascular outcomes in patients with stable angina., Methods: Multicenter 3-year follow-up study of patients with new onset stable angina and ≥ 30% stenosis by CTA. The lesion-specific FFR CT value (two cm-distal-to-stenosis) was registered in all vessels with stenosis and considered abnormal when ≤ 0.80. Patients with FFR CT ≤ 0.80 were categorized as: Completely revascularized (CR-FFR CT ), all vessels with FFR CT ≤ 0.80 revascularized; incompletely revascularized (IR-FFR CT ), ≥ 1 vessels with FFR CT ≤ 0.80 non-revascularized. Early revascularization (< 90 days from index CTA) categorized vessels as revascularized. The primary endpoint comprised cardiovascular death and non-fatal myocardial infarction; the secondary endpoint vessel-specific late revascularization and non-fatal myocardial infarction., Results: Amongst 900 patients and 1759 vessels, FFR CT was ≤ 0.80 in 377 (42%) patients, 536 (30%) vessels; revascularization was performed in 244 (27%) patients, 340 (19%) vessels. Risk of the primary endpoint was higher for IR-FFR CT (15/210 [7.1%]) compared to CR-FFR CT (4/167 [2.4%]), RR: 2.98; 95% CI: 1.01-8.8, p ​= ​0.036, and to normal FFR CT (3/523 [0.6%]), RR: 12.45; 95% CI: 3.6-42.6, p ​< ​0.001. Incidence of the secondary endpoint was higher in non-revascularized vessels with FFR CT ≤ 0.80 (29/250 [12%]) compared to revascularized vessels with FFR CT ≤ 0.80 (5/286 [1.7%]), p ​= ​0.001, and to vessels with FFR CT > 0.80 (10/1223 [0.8%]), p ​< ​0.001., Conclusion: Incomplete revascularization of patients with lesion-specific FFR CT ≤ 0.80 is associated to unfavorable cardiovascular outcomes compared to those with complete revascularization or FFR CT > 0.80., Competing Interests: Declaration of competing interest CR is a full-time employee of HeartFlow, and receives salary and stock options from HeartFlow. ELG has no conflicts related to this manuscript but has received speaker honoraria or consultancy fees from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Pfizer, Lundbeck Pharma, Novo Nordisk and Organon. He is investigator in clinical studies sponsored by AstraZeneca, Idorsia or Bayer and has received unrestricted research grants from Boehringer Ingelheim. JL is a consultant and holds stock options in Circle CVI and HeartFlow. KN acknowledges support from the NIH and reports unrestricted institutional research support from Siemens Healthineers, Bayer, HeartFlow Inc and Novartis. MP has received research grants from Janssen, Bayer, Heartflow and NIH and is part of the following advisory boards: Janssen, Bayer, Heartflow, Phillips. SM is a full-time employee of HeartFlow, and shareholder of HeartFlow. TF is associated with the HeartFlow speakers bureau. All other authors had no disclosures to declare., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)