Revascularizing coronary artery disease in patients undergoing transcatheter aortic valve implantation

Abstract

Coronary artery disease (CAD) is common among p a t i e n t s u n d e r g o i n g t r a n s c a t h e t e r a o r t i c v a l v e implantation (TAVI) with a prevalence of up to 75%, and no clear recommendations around its treatment (1) and conflicting evidence around whether to perform coronary revascularization or not. Moreover, the role of revascularization on long-term morbidity and mortality is still not clear in octogenarians (2). Piccolo and colleagues (3) have provided an interesting editorial comment on our work (1), and further pointed out controversies with regards to revascularization of patients with CAD and undergoing TAVI.The authors also commented on their own results (4), based on an elegant age-and gender-matched analysis where they found a significant increase in the composite of cardiovascular death, myocardial infarction, or stroke at 1-year among TAVI patients with CAD. However, it should be highlighted that the authors found a similar risk of ischemic events during TAVI procedures among patients without CAD as compared to the matched population with CAD. Even when the complexity and severity of CAD is considered and the SYNTAX score is used to stratify CAD severity, the evidence is mixed with regards to mortality outcomes (5,6). Moreover, emerging data on completeness of revascularization is also conflicting. Indeed, while Van Mieghem and colleagues (7) suggested no influence of completeness of revascularization on mortality, a recent large analysis showed that incompleteness of revascularization and more severe CAD were independent predictors of mortality (6).Our findings indicate no benefit in 30-day and 1-year outcomes with a revascularization strategy. Notably, revascularized patients were at higher-risk of major vascular complications, although data were derived from percutaneous coronary intervention (PCI) undertaken through the transfemoral approach and much of the data analysed was subject to the inherent limitations of observational registries such as selection biases and unmeasured confounding. Revascularization strategiesIn terms of symptoms assessment, it is often difficult to rely upon them in this population and tools conventionally used in patients with stable angina to guide revascularization (i.e., fractional flow reserve) are still not well validated and widely used in the setting of severe aortic stenosis. Hence, it is reasonable to percutaneously revascularize ostial or

Evaluation and management of coronary artery disease in patients undergoing transcatheter aortic valve implantation

“…Van Rosendael et al assessed the impact of the timing of planned PCI on TAVI outcomes [44] . Patients either received PCI within 30 days pre-TAVI or greater than 30 days pre-TAVI.…”

Pre-implantation balloon-aortic valvuloplasty before transcatheter aortic valve implantation: is this still needed?

“…Indeed, in patients with high risk features for coronary obstruction on MDCT; narrow, tubular aorta with low coronary ostia, pBAV with aortography can evaluate the interaction of the leaflet with the coronary ostium (27). Such information enables defaulting to a procedural strategy that firstly minimises risk for coronary obstruction, as well as implementing preventive measurements for bailout procedures such as guidewire engagement of the ostium at risk should urgent stenting be required (28), or simply choosing certain type of valve system that does not jail the coronary ostia (29)(30)(31).…”

Unmet issues in transcatheter aortic valve implantation

“…While doing the pre-TAVI workup, we have learned that the prevalence of coronary artery disease in patients undergoing TAVI ranges, depending of definitions, from 50% to 75% (8,9). Therefore, Drs.…”