Recent studies, most often in the set- ting of a pre-TAVI evaluation, have demonstrated diagnostic sensitivity of >90%, specificity of 60% and accuracy of >90%.21 Contrast- enhanced coronary CT angiography may be safer than coronary angiography in selected patient populations, such as those with IE and vegeta- tions on the aortic valve. However, a positive con- trast-enhanced coronary CT angiogram, defined as the presence of epicardial CAD, requires con- firmation with invasive coronary angiography to establish the need for and extent of CABG. The risk of radiation exposure and renal failure because of the contrast injection should be taken into consideration. 4. The presence of uncorrected CAD has been shown to negatively impact both perioperative22,23 and late outcomes of surgery for VHD.19 . Accordingly, concomitant CABG has been favored. These stud- ies of concomitant CABG at the time of valve surgery have demonstrated little or no adverse impact on the acute perioperative mortality rate, despite increased cross-clamp and cardiopulmo- nary bypass times. Moreover, combined CABG CLINICAL STATEMENTS AND GUIDELINES and valve surgery reduces the rate of perioperative myocardial infarction, and incomplete revascular- ization is associated with greater postoperative LV systolic dysfunction and a reduced survival rate after surgery as compared with patients who receive complete revascularization. For more than a decade, improved myocardial preservation tech- niques have been associated with reduced overall operative mortality rates, and it has become stan- dard practice to bypass all significant coronary artery stenoses, when possible, in patients under- going valve surgery. In patients with a significant stenosis of the left anterior descending artery, a left internal thoracic artery graft should be used if possible. Hybrid PCI followed by surgical valve repair or replacement has been reported favor- ably but is restricted to patients at high risk with a combined surgical approach.20 14.2. 