Outcomes in Patients With Transcatheter Aortic Valve Replacement and Left Main Stenting

Abstract

BACKGROUND A percutaneous approach with transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI) of the left main coronary artery (LM) is frequently used in high-risk patients with coexisting aortic stenosis and LM disease. Outcomes of TAVR plus LM PCI have not been previously reported. OBJECTIVES The primary objective of the TAVR-LM registry is to evaluate clinical outcomes in patients undergoing TAVR plus LM PCI. METHODS Clinical, echocardiographic, computed tomographic, and angiographic characteristics were retrospectively collected in 204 patients undergoing TAVR plus LM PCI. In total, 128 matched patient pairs were generated by performing 1:1 case-control matching between 167 patients with pre-existing LM stents undergoing TAVR and 1,188 control patients undergoing TAVR without LM revascularization. RESULTS One-year mortality (9.4% vs. 10.2%, p = 0.83) was similar between the TAVR plus LM PCI cohort and matched controls. One-year mortality after TAVR plus LM PCI was not different in patients with unprotected compared with protected LMs (7.8% vs. 8.1%, p = 0.88), those undergoing LM PCI within 3 months compared with those with LM PCI greater than 3 months before TAVR (7.4% vs. 8.6%, p = 0.61), and those with ostial versus nonostial LM stents (10.3% vs. 15.6%, p = 0.20). Unplanned LM PCI performed because of TAVR-related coronary complication, compared with planned LM PCI performed for pre-existing LM disease, resulted in increased 30-day (15.8% vs. 3.4%, p = 0.013) and 1-year (21.1% vs. 8.0%, p = 0.071) mortality. CONCLUSIONS Despite the anatomic proximity of the aortic annulus to the LM, TAVR plus LM PCI is safe and technically feasible, with short- and intermediate-term clinical outcomes comparable with those in patients undergoing TAVR alone. These results suggest that TAVR plus LM PCI is a reasonable option for patients who are at high risk for surgery.

Stenting the Snorkel: PCI of a Restenosed Left Main Stent Placed for Coronary Obstruction after Valve in Valve TAVR

“…The long-term concerns of a stent extruding into the aorta, especially behind the side cells of a TAVR valve, is stent patency and the ability to re-engage the stent for further treatment should this be necessary. A review of the literature demonstrates that, while PCI of the left main de novo prior to and after TAVR has been performed, this is the first published case of repeat intervention through a snorkeled LM stent [9,10].…”

The safety of concomitant transcatheter aortic valve replacement and percutaneous coronary intervention

“…[ 25 , 26 ] Left main revascularization during TAVR is well reported recently. [ 27 ] But further data and experience are needed to evaluate this single-stage strategy in these higher risk patients.…”

2020 Clinical practice guidelines for Stable coronary artery disease

“…• ЧКВ стенозов (более 70%) проксимальных сегментов КА должно быть рассмотрено у пациентов, которым планируется транскатетерная имплантация аортального клапана [73,154,155].…”