Abstract
The impact of coronary artery disease (CAD) on outcomes after transcatheter aortic valve implantation (TAVI) has not been clarified. Furthermore, less is known about the indication and strategy of revascularization in these high risk patients. This study sought to determine the prevalence and prognostic impact of CAD in patients undergoing TAVI, and to assess the safety and feasibility of percutaneous coronary intervention (PCI) before TAVI. Patients with severe aortic stenosis (AS) undergoing TAVI were included into a prospective single center registry from 2007 to 2012. Clinical outcomes were compared between patients with and without CAD. In some patients with CAD, it was decided to perform elective PCI before TAVI after decision by the Heart team. The primary endpoints were 30-day and 2-year all-cause mortality. A total of 91 consecutive patients with mean age of 79 ± 9 years (52% men) underwent TAVI with a median follow-up duration of 16 months (interquartile range of 27.6 months). CAD was present on 46 patients (51%). At 30-day, the incidences of death were similar between CAD and non-CAD patients (9 and 5%, p = 0.44), but at 2 years were 50% in CAD patients and 24% in non-CAD patients [crude hazard ratio with CAD, 2.2; 95% confidence interval (CI), 1.1-4.6; p = 0.04]. Adjusting for age, gender, left ventricular ejection fraction, and glomerular filtration rate, the hazard of death was 2.6-fold higher in patients with CAD (95% CI, 1.1-6.0; p = 0.03). Elective PCI before TAVI was performed in 13 patients (28% of CAD patients). There were no more adverse events in patients who underwent TAVI + PCI when compared with those who underwent isolated TAVI. In severe symptomatic AS who underwent TAVI, CAD is frequent and adversely impacts long-term outcomes, but not procedure outcomes. In selected patients, PCI before TAVI appears to be feasible and safe.
Highlights
The impact of coronary artery disease (CAD) on outcomes after transcatheter aortic valve implantation (TAVI) has not been clarified
CAD was present on 46 patients (51%)
At 30-day, the incidences of death were similar between CAD and non-CAD patients (9 and 5%, p = 0.44), but at 2 years were 50% in CAD patients and 24% in non-CAD patients [crude hazard ratio with CAD, 2.2; 95% confidence interval (CI), 1.1–4.6; p = 0.04]
Summary
The impact of coronary artery disease (CAD) on outcomes after transcatheter aortic valve implantation (TAVI) has not been clarified. Improved long-term survival has been reported in patients with AS and CAD who underwent combined SAVR and CABG compared with those receiving isolated SAVR [2] Based on these findings, current guidelines recommend bypass surgery to all significant stenosis at the time of SAVR [3, 4]. The original TAVI protocol precludes that significant CAD must be treated by percutaneous coronary intervention (PCI) before TAVI, and that CAD not treatable by PCI should be considered a formal contraindication for TAVI [4, 10] It is unknown if revascularization in the high-risk population referred to TAVI is associated with similar benefits to those observed in patient referred to SAVR. Since CABG is the primary mode of revascularization in patients with CAD and moderate to severe www.frontiersin.org
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