Impact of residual coronary atherosclerosis on transfemoral transcatheter aortic valve replacement

Abstract

Objectives This study reports on the clinical effects of complete vs incompletely revascularized coronary artery disease on transcatheter aortic valve replacement (TAVR). Background There is a high prevalence of active coronary artery disease (CAD) in patients undergoing TAVR but preemptive revascularization remains controversial. Methods Patients were categorized into three cohorts: complete revascularization (CR), incomplete revascularization of a major epicardial artery (IR Major), and incomplete revascularization of a minor epicardial artery only (IR Minor). When feasible, SYNTAX scoring was performed for exploratory analysis. Analyses were performed using Cox proportional hazard models and Kaplan–Meier method. Results A total of 323 patients with active CAD were included. Adjusted outcomes showed that patients with IR Major had increased incidence of acute myocardial infarction (AMI) or revascularization compared with those in the CR cohort (HR 3.72, P = 0.048). No difference was noted in all‐cause mortality or all‐cause readmission rates. Exploratory secondary analysis with residual SYNTAX scores showed a significant interaction between disease burden and AMI/revascularization, as well as all‐cause readmission. All‐cause mortality remained unaffected based on residual SYNTAX scores. Conclusions This is a retrospective single‐center study reporting on pre‐TAVR revascularization outcomes in patients with active CAD. In this analysis, we found that patients undergoing TAVR benefited from achieving complete revascularization to abate future incidence of AMI/revascularization. Despite this finding, all‐cause mortality remained unaffected. Future efforts should focus on the role of functional assessment of the coronaries, as well as the long‐term effects of complete revascularization in a larger patient cohort.

Unravelling the Fate of Coronary Artery Disease in Patients Undergoing Valve Replacement for Severe Aortic Valve Stenosis

“…Several studies have shown a correlation between incomplete revascularization (high residual SS) and worse clinical outcomes such as increased mortality or major adverse cardiac or cerebrovascular events (MACCE) supporting PCI in the peri-TAVI period [83][84][85][86][87][88]. However, other studies could not find an association between incomplete revascularization and clinical events [38,[89][90][91][92][93]. Recently, two important papers regarding this topic were published.…”

“…Limitations in combining the results of these studies lie in differences in the definition of incomplete revascularization, follow-up times and comorbidities, and overall small patients numbers in the cohorts studied (Table 2, Ref. [16,38,[83][84][85][86][87][88][89][90][91][92][93][94]). To date, only one randomized clinical trial comparing TAVI with medical therapy vs TAVI with PCI in patients with severe AS and CAD has been performed [95].…”

“…Limitations in combining the results of these studies lie in differences in the definition of incomplete revascularization, follow-up times and comorbidities, and overall small patients numbers in the cohorts studied (Table 2 , Ref. [ 16 , 38 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 ]).…”

Coronary Artery Disease and Revascularization in Patients Undergoing Transcatheter Aortic Valve Replacement

“…Several studies have quantified CAD burden with the SYNTAX score (SS) as an objective measure of CAD severity in evaluating link with TAVR outcomes [ 31 , 32 , 33 , 34 , 35 , 36 ]. In the study by Stefanini et al ., baseline and residual SS were determinants of adverse outcomes.…”

Transcatheter aortic valve implantation combined with other heart interventions: current status and future perspectives

“…PCI before TAVI, on the other hand, has the potential to minimize ischemic risk during TAVI, particularly during rapid ventricular pacing, and to overcome difficulties associated with coronary access post-TAVI. Conversely, the patient remains at risk for valvular decompensation and needs to be put on dual antiplatelet therapy, which may increase the risk of bleeding during TAVI [11][12][13] . PCI after TAVI is relatively rare because prosthetic valve commissures, or stent frame, may be positioned close to coronary ostia, interfering with coronary diagnostic or guiding catheters [14] .…”