Management of Myocardial Revascularization in Patients With Stable Coronary Artery Disease Undergoing Transcatheter Aortic Valve Implantation

Abstract

Background: The best management of stable coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) is still unclear due to the marked inconsistency of the available evidence. Methods: The REVASC-TAVI registry (Management of Myocardial Revascularization in Patients Undergoing Transcatheter Aortic Valve Implantation With Coronary Artery Disease) collected data from 30 centers worldwide on patients undergoing TAVI who had significant, stable CAD at preprocedural work-up. For the purposes of this analysis, patients with either complete or incomplete myocardial revascularization were compared in a propensity score matched analysis, to take into account of baseline confounders. The primary and co-primary outcomes were all-cause death and the composite of all-cause death, stroke, myocardial infarction, and rehospitalization for heart failure, respectively, at 2 years. Results: Among 2407 patients enrolled, 675 pairs of patients achieving complete or incomplete myocardial revascularization were matched. The primary (21.6% versus 18.2%, hazard ratio‚ 0.88 [95% CI, 0.66–1.18]; P =0.38) and co-primary composite (29.0% versus 27.1%, hazard ratio‚ 0.97 [95% CI, 0.76–1.24]; P =0.83) outcome did not differ between patients achieving complete or incomplete myocardial revascularization, respectively. These results were consistent across different prespecified subgroups of patients (< or >75 years of age, Society of Thoracic Surgeons score > or <4%, angina at baseline, diabetes, left ventricular ejection fraction > or <40%, New York Heart Association class I/II or III/IV, renal failure, proximal CAD, multivessel CAD, and left main/proximal anterior descending artery CAD; all P values for interaction >0.10). Conclusions: The present analysis of the REVASC-TAVI registry showed that, among TAVI patients with significant stable CAD found during the TAVI work-up, completeness of myocardial revascularization achieved either staged or concomitantly with TAVI was similar to a strategy of incomplete revascularization in reducing the risk of all cause death, as well as the risk of death, stroke, myocardial infarction, and rehospitalization for heart failure at 2 years, regardless of the clinical and anatomical situations.

Response by Costa et al to Letter Regarding Article, “Management of Myocardial Revascularization in Patients With Stable Coronary Artery Disease Undergoing Transcatheter Aortic Valve Implantation”

“…Of note, when comparing complete and incomplete revascularization groups, we did not observe any difference if patients receiving incomplete revascularization, underwent or not percutaneous coronary intervention (primary outcome 21.6% versus 18.5% versus 18.0% for complete revascularization, incomplete revascularization receiving percutaneous coronary intervention or medical therapy, respectively; P =0.63). 2 Moreover, we demonstrated the lack of impact if CAD involved proximal coronary segments, more than one coronary artery, or left main/proximal segment of left anterior descending artery. We agree that an evaluation of CAD with the use of Syntax score could be helpful for a better understanding of disease’s complexity, but this datum was not reported in all patients enrolled in the registry, and therefore we decided to not include it in the matching adjustment.…”

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

“…One prospective study with 5-year follow-up showed there was no benefit of (complete) revascularization for stable CAD in TAVI patients [16]. A large retrospective registry among TAVI patients with significant stable CAD showed no benefit of complete myocardial revascularization to reduce the risk of all cause death at 2 years [94]. 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.…”

“…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].…”

Letter by Minten et al Regarding Article, “Management of Myocardial Revascularization in Patients With Stable Coronary Artery Disease Undergoing Transcatheter Aortic Valve Implantation”

“…Letter by Minten et 1 about the effects of complete revascularization of stable CAD in patients undergoing TAVI. We would like to congratulate the authors for this nicely executed multicenter study.…”

“…Stable coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI): what are the real questions? We read with great interest the study by Costa et al 1 about the effects of complete revascularization of stable CAD in patients undergoing TAVI. We would like to congratulate the authors for this nicely executed multicenter study.…”