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Although conventional coronary angiography (CAG) is considered the gold standard for coronary artery disease (CAD) screening in the setting of heart valve surgery, coronary artery computed tomography angiography (CCTA) has emerged as an alternative modality. This study was conducted to evaluate the clinical outcomes of CCTA compared with conventional CAG for CAD screening in patients undergoing heart valve surgery.A total of 3150 consecutive patients aged >40 years or with coronary risk factors undergoing elective valve operations between 2001 and 2015 were evaluated. Of these, 1402 patients underwent CCTA (CT group) and 1748 patients underwent conventional CAG (CAG group) for CAD screening.The 30-day mortality rates were similar in the 2 groups (2.1% in the CT group vs 1.7% in the CAG group; P = .463); however, the incidence of low cardiac output syndrome was higher in the CT group (2.3% vs 1.0%; P = .008). The final rate of detection of significant CAD (≥50% stenosis) (4.9% vs 9.7%; P < .001) and proportion of receiving coronary bypass grafting (CABG) (2.9% vs 4.3%; P = .041) were lower in the CT group. After adjustment by propensity score matching (563 pairs), the main findings of our crude analyses did not change, with lower rates of CAD detection (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.36-0.85) and CABG (OR, 0.47; 95% CI, 0.26-0.81), a similar risk of early mortality (OR, 1.51; 95% CI, 0.54-4.52), but a higher risk of low cardiac output syndrome (OR, 3.30; 95% CI, 1.16-11.78) in the CT group compared with the CAG group.The detection of significant CAD and identification of candidates for CABG were inferior with CCTA compared with conventional CAG in patients scheduled for elective heart valve operations.