ACTIVATION (PercutAneous Coronary inTervention prIor to transcatheter aortic VAlve implantaTION)

Patterson, Tiffany; Clayton, Tim; Dodd, Matthew; Khawaja, Zeeshan; Morice, Marie Claude; Wilson, Karen M.; Kim, Won-Keun; Meneveau, Nicolas; Hambrecht, Rainer; Byrne, Jonathan; Carrié, Didier; Fraser, Doug; Roberts, David H.; Doshi, Sagar N.; Zaman, Azfar; Banning, Adrian; Eltchaninoff, Hélène; Breton, Hervé; Smith, David; Cox, Ian; Frank, Derk; Gershlick, Anthony; Belder, Mark de; Thomas, Martyn; Hildick‐Smith, David; Prendergast, Bernard; Redwood, Simon; Pocock, Stuart J.; Wang, Duolao; Irague, Florian

doi:10.1016/j.jcin.2021.06.041

Cited by 131 publications

(102 citation statements)

References 7 publications

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“…Expert consensus opinion (class IIa, level of evidence C) highlights that percutaneous coronary intervention (PCI) should be considered in AS-patients with a primary indication to undergo TAVR who have stenosis of at least 70% DS in the proximal segments of epicardial coronary arteries that subtend a large area of myocardium at risk (7,10). This has been recently challenged with the results from the Assessing the Effects of Stenting in Significant Coronary Artery Disease Prior to Transcatheter Aortic Valve Implantation (ACTIVATION) trial (26). Obviously, the optimal management of AS-patients with concomitant CAD in patients undergoing TAVR remains controversial due to the heterogeneity of available data, and the clinical relevance of PCI performed before or immediately after TAVR remains to be determined (2,5,(27)(28)(29).…”

Section: Introductionmentioning

confidence: 99%

Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis

Aleksandric¹,

Banović²,

Beleslin³

2022

Front. Cardiovasc. Med.

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More than half of patients with severe aortic stenosis (AS) over 70 years old have coronary artery disease (CAD). Exertional angina is often present in AS-patients, even in the absence of significant CAD, as a result of oxygen supply/demand mismatch and exercise-induced myocardial ischemia. Moreover, persistent myocardial ischemia leads to extensive myocardial fibrosis and subsequent coronary microvascular dysfunction (CMD) which is defined as reduced coronary vasodilatory capacity below ischemic threshold. Therefore, angina, as well as noninvasive stress tests, have a low specificity and positive predictive value (PPV) for the assessment of epicardial coronary stenosis severity in AS-patients. Moreover, in symptomatic patients with severe AS exercise testing is even contraindicated. Given the limitations of noninvasive stress tests, coronary angiography remains the standard examination for determining the presence and severity of CAD in AS-patients, although angiography alone has poor accuracy in the evaluation of its functional severity. To overcome this limitation, the well-established invasive indices for the assessment of coronary stenosis severity, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), are now in focus, especially in the contemporary era with the rapid increment of transcatheter aortic valve replacement (TAVR) for the treatment of AS-patients. TAVR induces an immediate decrease in hyperemic microcirculatory resistance and a concomitant increase in hyperemic flow velocity, whereas resting coronary hemodynamics remain unaltered. These findings suggest that FFR may underestimate coronary stenosis severity in AS-patients, whereas iFR as the non-hyperemic index is independent of the AS severity. However, because resting coronary hemodynamics do not improve immediately after TAVR, the coronary vasodilatory capacity in AS-patients treated by TAVR remain impaired, and thus the iFR may overestimate coronary stenosis severity in these patients. The optimal method for evaluating myocardial ischemia in patients with AS and co-existing CAD has not yet been fully established, and this important issue is under further investigation. This review is focused on challenges, limitations, and future perspectives in the functional assessment of coronary stenosis severity in these patients, bearing in mind the complexity of coronary physiology in the presence of this valvular heart disease.

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Section: Introductionmentioning

confidence: 99%

Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis

Aleksandric¹,

Banović²,

Beleslin³

2022

Front. Cardiovasc. Med.

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“…However, there was a higher rate of bleeding in the PCI group (44.5% versus 28.4%, p=0.02) in the first 30 days after the TAVI procedure. [ 43 ]…”

Section: Intervention In Tavi Patientsmentioning

confidence: 99%

Coronary Artery Disease in Patients with Aortic Stenosis and Transcatheter Aortic Valve Implantation: Implications for Management

Filho¹,

Accorsi

Ribeiro

2021

Eur Cardiol

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Aortic valve stenosis (AS) is the most common valvular heart disease among elderly patients. Since the pathophysiology of degenerative AS shares common pathways with atherosclerotic disease, the severity of AS in the elderly population is often concurrent to the presence of coronary artery disease (CAD). Although surgical aortic valve replacement has been the standard treatment for severe AS, the high operative morbidity and mortality in complex and fragile patients was the trigger to develop less invasive techniques. Transcatheter aortic valve implantation (TAVI) has been posed as the standard of care for elderly patients with severe AS with various risk profiles, which has meant that the concomitant management of CAD has become a crucial issue in such patients. Given the lack of randomised controlled trials evaluating the management of CAD in TAVI patients, most of the recommendations are based on retrospective cohort studies so that the Heart Team approach – together with an assessment of multiple parameters including symptoms and clinical characteristics, invasive and non-invasive ischaemic burden and anatomy – are crucial for the proper management of these patients. This article provides a review of current knowledge about assessment and therapeutic approaches for CAD and severe AS in patients undergoing TAVI.

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“…The ACTIVATION trial (RCT,n:235) compared PCI vs no-PCI prior to TAVR in patients with severe aortic stenosis and obstructive CAD. The observed rates of death (13.4% vs 12.1%) and rehospitalization at 1 year (34.5% vs 33.6%) were similar between PCI and no PCI prior to TAVR; however, the non-inferiority margin was not met, and PCI resulted in a higher incidence of bleeding (41.2% vs 21.7%) [ 11 ]. The majority of bleeding occurred in the first 30 days after TAVR.…”

Section: Introductionmentioning

confidence: 99%

2021. The year in review. Structural heart interventions

Marmagkiolis

Iliescu²,

Grines

et al. 2022

International Journal of Cardiology

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ACTIVATION (PercutAneous Coronary inTervention prIor to transcatheter aortic VAlve implantaTION)

Cited by 131 publications

References 7 publications

Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis

Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis

Coronary Artery Disease in Patients with Aortic Stenosis and Transcatheter Aortic Valve Implantation: Implications for Management

2021. The year in review. Structural heart interventions

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