Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions in collaboration with the ESC Working Group on Cardiovascular Surgery

Abstract

Significant coronary artery disease (CAD) is a frequent finding in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), and the management of these two conditions becomes of particular importance with the extension of the procedure to younger and lower-risk patients. Yet, the preprocedural diagnostic evaluation and the indications for treatment of significant CAD in TAVI candidates remain a matter of debate. In this clinical consensus statement, a group of experts from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery aims to review the available evidence on the topic and proposes a rationale for the diagnostic evaluation and indications for percutaneous revascularisation of CAD in patients with severe aortic stenosis undergoing transcatheter treatment. Moreover, it also focuses on commissural alignment of transcatheter heart valves and coronary re-access after TAVI and redo-TAVI.

Association Between Polyvascular Disease and Transcatheter Aortic Valve Replacement Outcomes: Insights From the STS/ACC TVT Registry

“…The decision to revascularize should be based on the presence of angina, presentation with acute coronary syndrome, lesion location, and angiographic severity coupled with invasive physiological assessment, where needed. [29][30][31] There are limited randomized data on revascularization and the optimal timing of PCI relative to TAVR. 32,33 PCI before TAVR is associated with easier coronary access and lower contrast volume, but the physiological assessment of indeterminate lesions may be unreliable.…”

“…32,33 PCI before TAVR is associated with easier coronary access and lower contrast volume, but the physiological assessment of indeterminate lesions may be unreliable. 31 On the contrary, concomitant PCI during TAVR warrants higher contrast load, prolonged procedure time, and need for dual antiplatelet therapy, thereby increasing the risk of acute kidney injury and bleeding complications post-TAVR. 31,34 Many trials are underway that will inform us on the timing, choice, and completeness of revascularization Stroke is a devastating complication after TAVR that occurs in ≈2% to 3% of patients 1,36,37 and is a consequence of embolization of calcium, fibrin, and connective tissue derived from the vessel wall and the aortic valve.…”

Acute heart failure and valvular heart disease: A scientific statement of the Heart Failure Association, the Association for Acute CardioVascular Care and the European Association of Percutaneous Cardiovascular Interventions of the European Society of Cardiology

“…[11][12][13][14][15][16] Afterload mismatch is initially responsible of decreasing in EF and stroke volume, but later on long-term exposure to pressure overload and demand ischaemia produce intrinsic myocardial contractility dysfunction with further decrease of EF, LV dilatation and secondary mitral regurgitation [11][12][13] • Various precipitants may intervene in different stages of severity and ventricular adaptation and may lead to decompensation, when SV is decreased at rest, and development of AHF [11][12][13][14][15][16] • Acute obstruction of aortic prosthetic valve may lead to AHF. The acute outflow obstruction, if left untreated, leads to a rapid clinical deterioration with decrease of SV and LV dilatation [11][12][13][14][15][16] • May present with any clinical profile • CS presentation is strongly related to mortality even after interventions 121,123 • RHF may occur in the later stages of AS evolution as consequence of PH or associated right-sided VHD 37 Severe AR • Haemolytic anaemia is the consequence of paravalvular leak 15,16,157 • RHF may occur as a consequence of PH or associated right-sided VHD • In 25% of patients, systolic dysfunction is also present due to chronic decrease of preload but also due to rheumatic cardiomyopathy [11][12][13][14][15][16] • Acute obstruction of mitral prosthetic valve may lead to AHF. The acute obstruction leads to a rapid clinical deterioration [11][12][13] • Resting symptoms usually develop ...…”

“…Routine revascularization of all significant coronary artery disease before TAVI in patients with no or minimal angina is not supported by the latest evidence 122 . In addition, other factors such as symptom severity, haemodynamic instability (either ischaemia‐induced or associated with AS), bleeding risk associated with antiplatelet therapy, amount of contrast use, duration of procedure and coronary access (very challenging post‐TAVI when a prosthesis with a supra‐annular leaflet position is chosen), are decisional for the appropriate timing 123 . However, there is currently insufficient evidence regarding the role and timing of PCI in AHF patients undergoing TAVI to inform clinical practice and the role of the Heart Team remains essential in this complex patient group.…”

Prognostic impact of coronary lesions and its revascularization in a 5‐year follow‐up after the TAVI procedure

“…Additionally, with the same level of evidence (Class I, level of evidence C), they recommend revascularization of proximal coronary lesions in all patients undergoing TAVI. 2,3 Based on these recommendations, a strategy of searching for and treating CAD in these patients has been implemented in most centers, without solid evidence to support this practice.…”