Clinical Impact of Pre-Procedural Percutaneous Coronary Intervention in Low- and Intermediate-Risk Transcatheter Aortic Valve Replacement Recipients.

Max-Paul Winter,Irene M Lang,Thomas M Hofbauer,Fabian Spinka,Philipp E Bartko,Georg Spinka,Carolina Donà,Georg Goliasch,Christian Nitsche,Markus Mach,Christian Hengstenberg,Julia Mascherbauer,Andreas A Kammerlander,Matthias Koschutnik,Martin Andreas,Raphael Rosenhek

doi:10.3390/jpm11070633

Abstract

The clinical relevance of as well as the optimal treatment strategy for coronary artery disease (CAD) in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS) are unclear. Current data are conflicting, and mainly derived from high-risk patients. We aimed to investigate the feasibility and safety of complete revascularization prior to TAVR for severe AS in low- and intermediate-risk patients. We enrolled 449 patients at low (STS score < 4%) and intermediate risk (STS score 4–8%) undergoing TAVR for severe AS and investigated the influence of recent (<3 months) and prior (>3 months) complete revascularization on clinical outcome. Primary study endpoint was all-cause mortality. Overall, 58% of patients had no or non-significant CAD; 18% had a history of complete revascularization prior to TAVR and 24% had complete revascularization shortly before TAVR. Two-year all-cause mortality was not different between patients with recent revascularization prior to TAVR and patients with no or non-significant CAD (13.7% vs. 14.2%, p = 0.905). Cox regression did not reveal an effect on all-cause mortality for recent revascularization. The present analysis reassures that percutaneous complete revascularization prior to TAVR procedures is neutral in terms of all-cause mortality in patients at low and intermediate surgical risk.

Highlights

The presence of significant coronary artery disease (CAD) in this patient cohort is not a reasonable comorbidity that indicates a potential benefit for conventional surgical aortic valve replacement (SAVR)
It remains paramount to discuss the coronary anatomy in interdisciplinary Heart Teams, with shared decision making to identify those patients that truly benefit from complete revascularization
CAD is prevalent among patients with aortic stenosis (AS) subjected to transcatheter aortic valve replacement (TAVR), even in patients deemed at low or intermediate surgical risk; whether previous percutaneous coronary intervention (PCI) influences outcome remains uncertain

Summary

Introduction

Transcatheter aortic valve replacement (TAVR) has revolutionized therapy of patients with severe symptomatic aortic valve stenosis (AS) who are at prohibitive risk for conventional surgical aortic valve replacement (SAVR) [1]. Considering that TAVR indication has expanded to include younger individuals with a longer life expectancy, attention needs to be brought to a holistic treatment strategy, encompassing all relevant cardiac comorbidities [4]. The clinical relevance of coronary artery disease (CAD) in patients undergoing TAVR for severe aortic stenosis is unclear. A recent meta-analysis including high-risk patients was unable to show benefit of revascularization prior to TAVR with respect to mortality [7].

Objectives

Methods

Results

Discussion

Conclusion