Abstract 14527: Utility of Routine Invasive Coronary Angiography Prior to Transcatheter Aortic Valve Replacement

Abstract

Introduction: Despite the high prevalence of CAD in patients with severe aortic stenosis (AS), the optimal management of concomitant coronary artery disease (CAD) before trasncatheter aortic valve replacement (TAVR) remains controversial. Hypothesis: To characterize the contemporary, real-world burden of CAD in contemporary TAVR patients and to evaluate revascularization practices at a high-volume center in the United States. Methods: Analysis of all adult patients referred for TAVR at our center between January 2019 and January 2020. Presence of significant coronary artery disease (stenosis >50%) and subsequent management (medical therapy versus revascularization) were recorded. Presenting symptoms, use of non-invasive and invasive ischemia testing and pre-TAVR computed tomography (CT) imaging were all analyzed. Results: A total of 394 patients with severe AS were referred to our institution for TAVR. Thirty-nine patients (9.9%) instead underwent surgical aortic valve replacement (SAVR), of which only 5 (1.3%) underwent SAVR plus coronary artery bypass surgery. Of the remaining 355 patients (77.3 ± 9.3 years old and 59.7% males), 218 patients (61.4%) had insignificant CAD. Of the 137 patients (38.6%) with significant CAD, only 30 (8.5%) underwent percutaneous coronary intervention (PCI). Of these, less than half had anginal symptoms, a third had CAD in proximal segments and a third underwent ischemia testing prior to PCI. Pre-TAVR CT accurately identified significant CAD in 28/30 patients (93.3%) who ultimately underwent PCI. Conclusions: Only 1 in 25 contemporary TAVR patients had significant CAD and anginal symptoms requiring intervention, questioning the utility of routine invasive coronary angiography before TAVR. A Heart Team approach integrating anginal symptoms and ischemia testing is needed to guide the need, timing and strategy of revascularization. The pre-TAVR CT images could identify significant proximal segment CAD needing PCI.