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Objective:
To examine the clinical feasibility and potential gate-keeper role of workstation-based fractional flow reserve (CT-FFR) in preprocedural CT planning in patients undergoing transcatheter aortic valve replacement (TAVR) with concomitant coronary artery disease (CAD).

Materials and Methods:
Overall, 434 patients undergoing TAVR between 2019 and 2020 were screened for study inclusion. Of these 112 were suitable for CT-FFR computation using standard CT data procured during TAVR planning. The employed software uses intricate fluid dynamic operations with recent developments of machine-learning algorithms enabling rapid computation of FFR across the lesions of interest in the same institute. CAD burden was additionally assessed via coronary calcium scores (CACS), and stenosis quantification. All patients were observed for major adverse cardiac events (MACE) during a 12-months follow-up succeeding TAVR implantation.

Results:
The prespecified endpoint was met in 17 patients (15.2%), with cardiovascular death being the most prevalent of the MACE composite. Of these, 13 patients had a positive CT-FFR (p = .002) eventuating in a relative risk ratio of 4.33 (p = .006, 95% CI 1.5 - 12.5). Thirty-five out of 46 patients (76.1%) with one or more significant stenosis (=70%) showed hemodynamic relevance as implied by CT-FFR. Compared to conventional CAD risk markers, CT-FFR performed best in predicting adverse outcomes (odds ratios 5.7 versus 1.6).

Conclusion:
At 12 months, there was a significantly greater occurrence of MACE in patients deemed of having CAD via consideration of cardiac CT and CT-FFR findings. Workstation based CT-FFR demonstrates signs of viability in a realistic clinical setting with the possibility to distinguish patients with a potential benefit of adjusted CAD treatment.