Concomitant Percutaneous Coronary Intervention Research Articles

Outcomes of concomitant percutaneous coronary intervention and balloon aortic valvuloplasty

Coronary artery disease often coexists with severe aortic stenosis. The feasibility and safety of combined balloon aortic valvuloplasty (BAV) and percutaneous coronary intervention (PCI) are unknown. To compare outcomes and complications of combined BAV and PCI with BAV alone. The study cohort consisted of 409 patients with severe aortic stenosis undergoing BAV from 1/2007 to 12/2010. Overall, 329 patients underwent BAV alone and 80 underwent concomitant PCI. Clinical and hemodynamic data, as well as acute and intermediate-term outcomes, were collected. At the operator's discretion PCI was done before BAV in 66 (82.5%) and after in 14 (17.5%). Patients who underwent concomitant procedures had a higher incidence of prior stroke and a lower incidence of atrial fibrillation. Procedure time and fluoroscopic time were significantly greater in the BAV/PCI group, (90.0 ± 36.6 vs. 72.8 ± 39.8, P = 0.002 and 20.5 ± 10.9 vs. 12.9 ± 7.0, P < 0.001). Significantly more radiographic contrast was used in the BAV/PCI group (95.1 ± 45.5 vs. 36.7 ± 38.4 cm(3) , P < 0.001. Serious adverse events occurred with equal frequency 13.7 and 17.3%, P = 0.44). Transfusion requirement was also similar (21.2% vs. 20.0%, P = 0.81). The frequency of a periprocedural increase in troponin or creatinine was also similar. In the BAV alone group the mortality rate was 48.6% (n = 160) during a mean follow-up of 191 days, and in the BAV/PCI group the mortality rate was 40% (n = 32) during mean follow-up of 175.5 day, P = 0.34. Combined BAV and PCI are safe and are associated with similar complications as BAV alone and may offer protection against myocardial ischemia during BAV.

C oncomitant Percutaneous Coronary Intervention and Transcatheter Aortic Valve Replacement: Safe and Feasible Replacement Alternative Approaches in High-Risk Patients with Severe Aortic Stenosis and Coronary Artery Disease

Transcatheter aortic valve replacement (TAVR) is performed as a stand-alone procedure in patients that are not suitable for surgical aortic valve replacement. However, a significant proportion of patients with severe aortic stenosis have coexisting coronary artery disease (CAD). We report concomitant TAVR and percutaneous coronary intervention (PCI) as a single procedure in such patients. Three patients with severe aortic stenosis and CAD that were high risk for conventional surgery had concomitant alternative approach TAVR and PCI performed. Two patients had PCI and stent placement immediately after the deployment of the transapical transcatheter aortic valve, and one patient had a coronary artery stent placed just prior to the deployment of the transaortic transcatheter aortic valve. Two male patients and one female (age range 68-91 years) had 100% procedural success with resolution of symptoms and zero residual stenosis. There were no complications related to neurologic events, worsening renal function, or myocardial infarction. In-hospital and 30-day mortality was zero. All three patients were discharged home with a median hospital stay of eight days. In our small series of patients presented we demonstrate that PCI and TAVR performed concurrently in the hybrid operating room is a feasible option in patients undergoing TAVR with coexisting CAD. Furthermore, we propose this single-stage approach in such high-risk patients as it decreases the number of procedures performed and may theoretically lower cost and hospital stay.

Complete Revascularization Is Not a Prerequisite for Success in Current Transcatheter Aortic Valve Implantation Practice

This study sought to assess in patients undergoing transcatheter aortic valve implantation (TAVI), the prevalence and impact of incomplete coronary revascularization defined as >50% coronary artery or graft diameter stenosis on visual assessment of the coronary angiogram. TAVI is an established treatment option in elderly patients with aortic stenosis (AS) and a (very) high operative risk. Coronary artery disease (CAD) is often associated with AS. A single-center cohort of consecutive patients undergoing TAVI between November 2005 and June 2012 was evaluated for the presence of significant CAD. The decision to revascularize and pursue complete revascularization was made by heart team consensus. A total of 263 consecutive patients with a mean age of 80 ± 7 years and 51% male underwent TAVI with a median follow-up duration of 16 months (interquartile range: 4.2 to 28.1months). Significant CAD with myocardium at risk was present in 124 patients (47%), 44 of whom had had previous coronary artery bypass grafting (CABG), and the median SYNTAX score in the 81patients without previous CABG was 9.00 (2.38 to 15.63). Staged percutaneous coronary intervention (PCI) was planned in 19 (15%) and concomitant PCI with TAVI in 20 (16%). The median post-procedural residual SYNTAX score of patients without prior CABG was 5.00 (0.13 to 9.88). Overall, 99 patients (37%) (61 with no CABG and 38 CABG patients) had incomplete revascularization afterTAVI. Revascularization status did not affect clinical endpoints. Kaplan-Meier survival curves for patients with and without complete revascularization demonstrated a 1-year mortality of 79.9% versus 77.4% (p= 0.85), respectively. In an elderly patient population undergoing TAVI for severe AS, a judicious revascularization strategy selection by a dedicated heart team can generate favorable mid-term outcome obviating the need for complete coronary revascularization.

Early and intermediate survival after transcatheter aortic valve implantation: systematic review and meta-analysis of 14 studies

BackgroundTranscatheter aortic valve implants (TAVIs) is indicated as an alternative to surgical valve replacement for patients unfit for surgery. No systematic review has studied survival after 2 years and limited...

Impact of coronary artery disease and percutaneous coronary intervention on outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation

Coronary artery disease (CAD) is frequently present in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). While revascularisation affects peri-operative outcome in patients undergoing surgical aortic valve replacement, the impact of percutaneous coronary intervention (PCI) in patients undergoing TAVI is not well established. Consecutive patients with severe AS undergoing TAVI were prospectively included into the Bern TAVI registry. In patients with CAD, myocardium at risk was assessed using the DUKE myocardial jeopardy score. Revascularisation was performed by means of PCI either staged or concomitant at the time of TAVI. Among 256 patients undergoing TAVI, 167 patients had CAD and 59 patients underwent either staged (n=23) or concomitant (n=36) PCI. Clinical outcome at 30 days was similar for patients undergoing isolated TAVI as compared with TAVI combined with PCI in terms of death (5.6% versus 10.2%, p=0.24), major stroke (4.1% versus 3.4%, p=1.00), and the VARC combined safety endpoint (31.0% versus 23.7%, p=0.33). A stratified analysis of outcomes according to presence of CAD or revascularisation showed no difference during long-term follow-up (log rank p=0.16). CAD is frequent among patients with severe AS undergoing TAVI. Among carefully selected patients, revascularisation by means of PCI can be safely performed in addition to TAVI either as a staged or a concomitant intervention.

Effect of Experience on Results of Transcatheter Aortic Valve Implantation Using a Medtronic CoreValve System

Outcome after transcatheter aortic valve implantation (TAVI) depends on the patient risk profile, operator experience, progress in technology, and technique. We sought to compare the results of TAVI during the initiation phase and after certification to perform TAVI with the Medtronic CoreValve System without proctoring. A total of 165 consecutive patients was categorized into a first cohort of 33 patients treated before certification (November 2005 to December 2007) and a second cohort of 132 patients treated after certification (January 2008 to October 2010). The study end points were selected and defined according to the Valve Academic Research Consortium recommendations. Compared to cohort 2, the patients in cohort 1 more frequently had New York Heart Association class III-IV (100% vs 71%, p <0.001), hypertension (67% vs 39%, p = 0.004), and aortic regurgitation grade III-IV (46% vs 22%, p = 0.006) before TAVI. Over time, the patients in cohort 2 more frequently underwent a truly percutaneous approach (98% vs 82%, p = 0.002) without circulatory support (96% vs 67%, p <0.001) but with more concomitant percutaneous coronary intervention (11% vs 0%, p = 0.042) than the patients in cohort 1. They also more often received a 29-mm prosthesis (72% vs 24%, p <0.001), required less postimplantation balloon dilation (10% vs 27%, p = 0.008), and had less aortic regurgitation grade III-IV after TAVI (12% vs 30%, p = 0.010). The clinical outcome showed a nonsignificant reduction in the combined safety end point (30% to 17%) but a significant reduction in cerebrovascular events (21% to 7%, p = 0.020) and life-threatening bleeding (15% to 5%, p = 0.044) in cohort 2. However, the reduction in overall bleeding and vascular complications (25% and 14%, respectively) was not significant. In conclusion, TAVI became significantly less complex and was associated with better results over time but remained associated with a high frequency of periprocedural major cardiovascular complications.

First experience with transcatheter aortic valve implantation and concomitant percutaneous coronary intervention

We investigated our experience with combined transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) as an alternative strategy in high-risk patients. Combined surgical aortic valve replacement and coronary artery bypass grafting are the gold standard treatment for patients with aortic stenosis and concomitant coronary artery disease. However, a substantial share of patients is unfit for surgery due to contraindications. Twenty-eight patients (15 female) underwent combined TAVI and PCI after being refused for surgery. In 21 patients (group 1) a staged approach of PCI prior to subsequent TAVI was chosen. Seven patients (group 2) were treated in a single-stage procedure. Mean patient age was 80.1±6.9years, pre-procedural risk assessment revealed a mean logEuroSCORE of 26.8±13.4%. Left ventricular ejection fraction was 45.6±11.1%. Baseline mean/peak transvalvular gradients were 40.2±16.8 and 65.6±26.6mmHg, respectively, and decreased to mean/peak values of 9.3±4.2/15.2±8.4mmHg (p<0.0001), effective orifice area increased from 0.73±0.25 to 1.74±0.47cm(2) (p<0.0001). In group 2, fluoroscopy time and amount of contrast agent were significantly higher compared to group 1 (18.1±9.2 vs. 9.5±7.0min; p=0.03/292.3±117.5 vs. 171.9±68.4ml; p=0.006). In group 1, patients received PCI 14.3±9.6days prior to TAVI. In group 2, PCI was performed immediately before TAVI. A mean of 1.6±1.0 stents was placed per patient. No periprocedural myocardial infarction or stroke occurred in any patient. Thirty-day mortality was 7.1% (2/28). Our strategy of staged or single-stage TAVI and PCI proved feasible and safe in this high-risk patient population. Whether there is advantage of one approach over the other remains to be elucidated.

Routine Intraoperative Completion Angiography After Coronary Artery Bypass Grafting and 1-Stop Hybrid Revascularization: Results From a Fully Integrated Hybrid Catheterization Laboratory/Operating Room

This study sought to report our experience with a routine completion angiogram after coronary artery bypass surgery (CABG) and simultaneous (1-stop) percutaneous coronary intervention (PCI) at the time of CABG performed in the hybrid catheterization laboratory/operating room. The value of a routine completion angiogram after CABG and 1-stop hybrid CABG/PCI remains unresolved. Between April 2005 and July 2007, 366 consecutive patients underwent CABG surgery, with (n = 112) or without (n = 254) concomitant 1-stop PCI (hybrid), all with completion angiography before chest closure. Among the 112 1-stop hybrid CABG/PCI patients, 67 (60%) underwent a planned hybrid procedure based on pre-operative assessment, whereas 45 (40%) underwent open-chest PCI (unplanned hybrid) based on intraoperative findings. Among the 796 CABG grafts (345 left internal mammary artery, 12 right internal mammary artery/radial, and 439 veins), 97 (12%) angiographic defects were identified. Defects were repaired with either a minor adjustment of the graft (n = 22, 2.8%), with intraoperative open-chest PCI (unplanned hybrid, n = 48, 6%) or with traditional surgical revision (n = 27, 3.4%). Hybrid patients had clinical outcomes similar to standard CABG patients. Routine completion angiography detected 12% of grafts with important angiographic defects. One-stop hybrid coronary revascularization is reasonable, safe, and feasible. Combining the tools of the catheterization laboratory and operating room greatly enhances the options available to the surgeon and cardiologist for patients with complex coronary artery disease.

Efficacy of N-acetylcysteine and hydration versus placebo and hydration in decreasing contrast-induced renal dysfunction in patients undergoing coronary angiography with or without concomitant percutaneous coronary intervention

Contrast-induced renal dysfunction is an iatrogenic complication that occurs more frequently in patients with preexisting renal dysfunction. A prospective, double-blind, randomized, placebo, controlled trial was completed to assess the efficacy of N-acetylcysteine in decreasing the incidence of contrast-induced renal dysfunction in patients with an acute coronary syndrome and renal insufficiency who underwent coronary angiography with or without percutaneous coronary intervention. With similar intravenous hydration protocols, 20 patients received N-acetylcysteine (treatment group) and 20 patients received placebo (control group) in a twice per day dosing regimen with one dose before and three doses after contrast media exposure. The two groups were similar at baseline on demographic and clinical characteristics, and preexisting renal insufficiency. Contrast-induced renal dysfunction, defined as an increase in serum creatinine greater than 44 micromol/L (.5 mg/dL) and/or 25% above baseline within 48 hours, occurred in 7.5% of the cohort, with 2.5% in the treatment group, and 5% in the control group, for an absolute difference of 2.5%. There was no difference in serum creatinine or creatinine clearance at 24 hours or at 48 hours between the treatment and control groups. These results suggest that this cohort gained no added protection to renal function with the use of N-acetylcysteine.