Coronary Artery Disease and Aortic Stenosis in the Transcatheter Aortic Valve Replacement Era

Abstract

Significant coronary artery disease (CAD) is present in up to 50% of patients with symptomatic aortic stenosis (AS). Although numerous databases have shown that the addition of bypass grafting to an aortic valve replacement (AVR) nearly doubles the mortality, surgical series have shown that leaving significant coronary stenosis untreated increases AVR mortality.1–4 Thus, the standard of care for this population has been concomitant coronary artery bypass grafting along with surgical aortic valve replacement. Article see p 1005 Historically, the role of percutaneous coronary intervention (PCI) in the setting of severe AS has been limited and mainly directed to patients with acute coronary syndrome. However, PCI has been occasionally used in treating those patients in whom the risk of surgical AVR is prohibitive in attempts to palliate symptoms or to differentiate coronary from valvular syndromes. Recently, several new indications for PCI in the setting of AS have been proposed: in the context of hybrid procedures using PCI with AVR and in patients undergoing transcatheter aortic valve replacement (TAVR). Several groups have been investigating the role of hybrid procedures for the treatment of concomitant CAD and AS. Percutaneous coronary intervention either immediately preceding or simultaneously with surgery has been shown in limited series to be safe.5 Admittedly, there may be a strong publication bias favoring studies with superior outcomes, and larger studies are underway. The goal of hybrid procedures is to reduce a higher-risk coronary artery bypass grafting (CABG)/AVR to 2 potentially lower-risk and less morbid procedures. There are at least 2 important considerations raised by this concept. First, can PCI be performed safely in the setting of AS, and if so what is the best timing for it? Second, what is the impact of the necessary dual antiplatelet therapy on bleeding with surgery? There are …