One more step for computed tomography coronary angiography before heart valve surgery.

Coronary angiography (CA) to screen for the presence of coronary artery disease (CAD) is routinely performed before elective heart valve surgery. Its use is liberally advocated across a wide spectrum of patients by the writing committees for the treatment of patients with valvular heart disease (VHD) of the American College of Cardiology/ American Heart Association and the European Society of Cardiology.1,2 Class I indications, all with level of evidence C, include men 35 to 40 years or older, postmenopausal women, and premenopausal women with coronary risk factors, in addition to the more traditional considerations of suspected myocardial ischemia, left ventricular systolic dysfunction, and any history or other signs of CAD. These recommendations are predicted on 2 major factors; namely, that clinical, ECG, echocardiographic, and radionuclide markers are less specific for CAD in the setting of severe VHD and that perioperative and long-term outcomes are improved in patients with significant CAD undergoing combined valve and coronary bypass surgery compared with patients in whom revascularization is not performed. The evidence base for this latter claim derives primarily from older, single-center observational studies in patients with aortic stenosis (AS) and CAD.3,4 The more recent application of “hybrid” percutaneous coronary intervention with less invasive valvular heart surgery is gaining increasing acceptance,5 though there remains concern regarding the hazards and timing of dual antiplatelet therapy and institutional practices vary widely.