Acute Coronary Syndrome Following Transcatheter Aortic Valve Replacement

Abstract

Background: Scarce data exist on coronary events following transcatheter aortic valve replacement (TAVR), and no study has determined the factors associated with poorer outcomes in this setting. This study sought to determine the clinical characteristics, outcomes, and prognostic factors of acute coronary syndrome (ACS) events following TAVR. Methods: Multicenter cohort study including a total of 270 patients presenting an ACS after a median time of 12 (interquartile range, 5–17) months post-TAVR. Post-ACS death, myocardial infarction, stroke, and overall major adverse cardiovascular or cerebrovascular events were recorded. Results: The ACS clinical presentation consisted of non–ST-segment–elevation myocardial infarction (STEMI) type 2 (31.9%), non–STEMI type 1 (31.5%), unstable angina (28.5%), and STEMI (8.1%). An invasive strategy was used in 163 patients (60.4%), and a percutaneous coronary intervention was performed in 97 patients (35.9%). Coronary access issues were observed in 2.5% and 2.1% of coronary angiography and percutaneous coronary intervention procedures, respectively. The in-hospital mortality rate was 10.0%, and at a median follow-up of 17 (interquartile range, 5–32) months, the rates of death, stroke, myocardial infarction, and major adverse cardiovascular or cerebrovascular events were 43.0%, 4.1%, 15.2%, and 52.6%, respectively. By multivariable analysis, revascularization at ACS time was associated with a reduction of the risk of all-cause death (hazard ratio, 0.54 [95% CI, 0.36–0.81] P =0.003), whereas STEMI increased the risk of all-cause death (hazard ratio, 2.06 [95% CI, 1.05–4.03] P =0.036) and major adverse cardiovascular or cerebrovascular events (hazard ratio, 1.97 [95% CI, 1.08–3.57] P =0.026). Conclusions: ACS events in TAVR recipients exhibited specific characteristics (ACS presentation, low use of invasive procedures, coronary access issues) and were associated with a poor prognosis, with a very high in-hospital and late death rate. STEMI and the lack of coronary revascularization determined an increased risk. These results should inform future studies to improve both the prevention and management of ACS post-TAVR.

The need for future coronary access following surgical or transcatheter aortic valve replacement

“…This study also found that only 53.3% of patients who required coronary access post‐AVR returned to the same hospital where they received their initial AVR. This finding emphasizes the need for all catheterization facilities to be facile in managing coronary engagement and PCI through especially a transcatheter aortic valve, particularly since many patients may require treatment for an acute coronary syndrome after having an TAVR 18,19,31 . Although this study demonstrated that the need for coronary engagement was significantly higher for TAVR patients who had PCI 6 months prior to their AVR and for TAVR patients with a history of CAD, this study does not address whether coronary revascularization prior to TAVR improves clinical outcomes.…”

“…However, given the progressive nature of CAD, these lower risk and younger patients may more likely develop symptomatic CAD post AVR given their longer survival horizon, increasing the need for future coronary reaccess and transcatheter revascularization. The consensus across studies that have evaluated PCI and angiograms after an AVR is that in both SAVR and TAVR coronary access and PCI is possible and relatively safe, but can be challenging depending on patient‐prosthesis geometric relationships 7,9,17–22,25–31 . Despite the importance of CAD post‐AVR, scant data exists regarding the need for coronary access post AVR, and understanding of post‐TAVR and post‐SAVR PCI frequency would help inform procedural planning and potentially valve selection.…”

Incidence, treatment, and outcomes of acute myocardial infarction following transcatheter or surgical aortic valve replacement

“…Moreover, recent studies reported that half of NSTEMI following TAVR was type 2 NSTEMI, 8,9 suggesting that type 2 NSTEMI is common and is treated without an invasive coronary strategy in this population. Although we could not distinguish between type 1 and type 2 NSTEMI in the present study, a new ICD-10 code for type 2 MI (I21.A1) has started to be used since October 2017.…”

Role of coronary angiogram before transcatheter aortic valve implantation

“…Access to coronary arteries following TAVI has been reported to be challenging[ 28 - 30 ]. This was highlighted with self-expanding compared to balloon-expanding valves[ 31 ].…”

“…This should not be surprising since other mechanisms of MI were proposed such as coronary embolism secondary to subclinical leaflet thrombosis, late migration of the bioprosthetic valve, impaired coronary flow dynamic, and coronary hypo-perfusion related the valve bio-prosthesis[ 32 ]. Moreover, Faroux et al [ 30 ] showed that most coronary lesions were newly developed lesions that were not flow limiting prior to their valve procedure in patients presenting with acute coronary syndrome following TAVI[ 30 ]. This was reflected in our data whereby there was no difference in events rates according to the presence of flow limiting lesions before TAVI.…”