Figure - available from: BMC Cardiovascular Disorders
This content is subject to copyright. Terms and conditions apply.
Study flow chart. AS aortic stenosis; CAD coronary artery disease; PCI percutaneous coronary intervention; TAVR transcatheter aortic valve replacement
Source publication
Objectives
The aim of the study was to analyze the impact of concomitant coronary artery disease (CAD) assessed by the SYNTAX score (SS) and periprocedural percutaneous coronary intervention (PCI) on outcomes after transcatheter aortic valve replacement (TAVR).
Background
Due to controversial data regarding the effect of CAD on outcomes after TAVR...
Similar publications
Coronary artery disease (CAD) and aortic stenosis share similar risk factors and underlying pathophysiology. Up to half of the patient population undergoing work-up for aortic valve replacement have underlying CAD, which can affect outcomes in patients with more severe disease. As the indications for transcatheter aortic valve replacement (TAVR) ha...
Background: Aortic stenosis is a progressive and degenerative disease, which at some stage needs an aortic valve replacement (AVR). Despite an almost equal prevalence of aortic stenosis, female referral to AVR is lower and unexplained, although partly explained in the differences in risk and outcome. The introduction of transcatheter aortic valve r...
Background:
Information regarding the outcomes of transcatheter aortic valve replacement (TAVR) in men is limited. This study aimed to investigate short- to mid-term outcomes and prognostic predictors in this population.
Method and results:
The data of 519 men were analyzed from 1,693 consecutive patients with symptomatic severe aortic stenosis...
Background:
The indication for transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS) significantly varies among physicians and institutions.
Objectives:
This study aims to develop a set of appropriate use criteria for AS management to assist physicians in decision-making.
Methods:
The RAND-modified Delphi panel method was used...
Citations
... 3,4 Nevertheless, indication for treatment of significant CAD in TAVI setting still remains a matter of debate, due to the marked inconsistency of the available evidence, which are mainly based on nonrandomized data. 2,[5][6][7][8][9][10][11][12] In fact, whether performing PCI and achieving complete revascularization in patients undergoing TAVI would offer a clinical benefit in patients with significant CAD remains unclear. 13 The randomized, noninferiority ACTIVATION trial (Percutaneous Coronary Intervention Prior to Transcatheter Aortic Valve Implantation) showed that rates of death and rehospitalization at 1 year were similar between PCI and no PCI prior to TAVI. ...
... [16][17][18] To date, the benefit of coronary revascularization in the setting of TAVI has been mainly investigated in small, nonrandomized studies, and results are contradictory. 5,6,8,10 The ACTIVATION study is the only randomized clinical trial that explored the benefit of PCI in patients undergoing TAVI with significant CAD. 14 The trial showed similar rates of the primary composite end point of allcause death and rehospitalization at 1 year in patients receiving PCI or not (41.5% versus 44.0%). ...
Background
The best management of stable coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) is still unclear due to the marked inconsistency of the available evidence.
Methods
The REVASC-TAVI registry (Management of Myocardial Revascularization in Patients Undergoing Transcatheter Aortic Valve Implantation With Coronary Artery Disease) collected data from 30 centers worldwide on patients undergoing TAVI who had significant, stable CAD at preprocedural work-up. For the purposes of this analysis, patients with either complete or incomplete myocardial revascularization were compared in a propensity score matched analysis, to take into account of baseline confounders. The primary and co-primary outcomes were all-cause death and the composite of all-cause death, stroke, myocardial infarction, and rehospitalization for heart failure, respectively, at 2 years.
Results
Among 2407 patients enrolled, 675 pairs of patients achieving complete or incomplete myocardial revascularization were matched. The primary (21.6% versus 18.2%, hazard ratio‚ 0.88 [95% CI, 0.66–1.18]; P =0.38) and co-primary composite (29.0% versus 27.1%, hazard ratio‚ 0.97 [95% CI, 0.76–1.24]; P =0.83) outcome did not differ between patients achieving complete or incomplete myocardial revascularization, respectively. These results were consistent across different prespecified subgroups of patients (< or >75 years of age, Society of Thoracic Surgeons score > or <4%, angina at baseline, diabetes, left ventricular ejection fraction > or <40%, New York Heart Association class I/II or III/IV, renal failure, proximal CAD, multivessel CAD, and left main/proximal anterior descending artery CAD; all P values for interaction >0.10).
Conclusions
The present analysis of the REVASC-TAVI registry showed that, among TAVI patients with significant stable CAD found during the TAVI work-up, completeness of myocardial revascularization achieved either staged or concomitantly with TAVI was similar to a strategy of incomplete revascularization in reducing the risk of all cause death, as well as the risk of death, stroke, myocardial infarction, and rehospitalization for heart failure at 2 years, regardless of the clinical and anatomical situations.
... Several studies have quantified CAD burden with the SYNTAX score (SS) as an objective measure of CAD severity in evaluating link with TAVR outcomes [31][32][33][34][35][36]. In the study by Stefanini et al., baseline and residual SS were determinants of adverse outcomes. ...
... Consistent findings have been observed in other studies looking at relationship between SS and post-TAVR outcomes [32,33]. Further, Stephan et al. [34] found that patients with concomitant CAD suffered more frequently from myocardial infarction (MI) post-TAVR, and that patients with a residual SS <8 showed significantly lower rates of one-year mortality. In these studies, extent and severity of CAD frequently correlated with higher comorbidity burden and greater risk profiles at baseline [3]. ...
Coronary artery disease (CAD) and aortic stenosis share similar risk factors and underlying pathophysiology. Up to half of the patient population undergoing work-up for aortic valve replacement have underlying CAD, which can affect outcomes in patients with more severe disease. As the indications for transcatheter aortic valve replacement (TAVR) have expanded to intermediate and now low risk patients, the optimal management of CAD in this patient population still needs to be determined. This includes both pre-TAVR evaluation for CAD as well as indications for revascularization in patients undergoing TAVR. There is also limited data on coronary interventions after TAVR, including the incidence, feasibility and outcomes of patients undergoing percutaneous coronary intervention (PCI) after TAVR. This review provides an updated report of the current literature on CAD in TAVR patients, focusing on its prevalence, impact on outcomes, timing of revascularization and potential challenges with coronary interventions post-TAVR.
... The European Society of Cardiology (ESC) guidelines recommend PCI for coronary artery diameter stenosis > 70% in proximal segments (Class of recommendation: IIa; Level of evidence: C) in patients undergoing TAVR with concomitant CAD, with dual antiplatelet therapy (DAPT) recommended after PCI with a duration established according to bleeding risk [2] (Table 1). Prior PCI seems to have a beneficial impact on the long-term prognosis of TAVR patients with concomitant CAD [69], as incomplete revascularization has been associated with a higher rate of mortality [79,[82][83][84]. There is a lack of robust data on the optimal strategy and timing of PCI among TAVR patients with concomitant CAD, since only one underpowered randomized trial evaluated the impact of prior PCI in this population [85]. ...
Due to a large technical improvement in the past decade, transcatheter aortic valve replacement (TAVR) has expanded to lower-surgical-risk patients with symptomatic and severe aortic stenosis. While mortality rates related to TAVR are decreasing, the prognosis of patients is still impacted by ischemic and bleeding complications, and defining the optimal antithrombotic regimen remains a priority. Recent randomized control trials reported lower bleeding rates with an equivalent risk in ischemic outcomes with single antiplatelet therapy (SAPT) when compared to dual antiplatelet therapy (DAPT) in patients without an underlying indication for anticoagulation. In patients requiring lifelong oral anticoagulation (OAC), the association of OAC plus antiplatelet therapy leads to a higher risk of bleeding events with no advantages on mortality or ischemic outcomes. Considering these data, guidelines have recently been updated and now recommend SAPT and OAC alone for TAVR patients without and with a long-term indication for anticoagulation. Whether a direct oral anticoagulant or vitamin K antagonist provides better outcomes in patients in need of anticoagulation remains uncertain, as recent trials showed a similar impact on ischemic and bleeding outcomes with apixaban but higher gastrointestinal bleeding with edoxaban. This review aims to summarize the most recently published data in the field, as well as describe unresolved issues.
... S-a demonstrat că incidența bolii arteriale coronariene (CAD) influențează rezultatul la pacienții cu stenoză aortică severă supuși TAVI. Cu toate acestea, relevanța CAD, cât și revascularizarea la pacienții supuși TAVI este încă în curs de dezbatere [21]. Conform ultimelor studii, pacienții cu CAD concomitent au prezentat rata de IM semnificativ crescută în primul an post-TAVI [21]. ...
... Cu toate acestea, relevanța CAD, cât și revascularizarea la pacienții supuși TAVI este încă în curs de dezbatere [21]. Conform ultimelor studii, pacienții cu CAD concomitent au prezentat rata de IM semnificativ crescută în primul an post-TAVI [21]. La pacienții selectați, PCI înainte de TAVI pare a fi fezabilă și sigură. ...
Aortic stenosis (AS) is a valvular heart disease commonly found in the elderly patients. Treatment should be initiated prompt after the diagnosis of symptomatic AS, due to its poor prognosis and a high death rate. Transcatheter aortic valve implantation (TAVI) is the elective treatment for elderly patients with AS and high surgical risk. This study aims to evaluate the preand post-TAVI echocardiographic parameters and the major adverse cardiovascular events (MACE) within the first 30 days and at 1 year, in the first 10 patients subjected to TAVI in the Republic of Moldova.
Objectives: To compare outcomes of complete transcatheter (TAVI plus PCI) versus complete surgical (SAVR plus CABG) approach to treat patients with aortic stenosis (AS) and concomitant coronary artery disease (CAD).
Methods: Study-level meta-analysis with reconstructed time-to-event data including studies published by November 2021. The primary endpoints were 30-day mortality, overall survival, and major adverse cardiovascular and cerebrovascular events (MACCE). The secondary endpoints were 30-day stroke, myocardial infarction, and permanent pacemaker implantation (PPI); in-hospital major vascular events and acute kidney injury (AKI).
Results: Eight studies met our eligibility criteria, including a total of 33,286 patients (3448 for TAVI plus PCI and 29,838 for SAVR plus CABG). The pooled risk of 30-day mortality was lower for TAVI plus PCI (OR 0.63; 95% CI 0.51-0.80; p < .001). Patients undergoing TAVI plus PCI had lower risk of in-hospital AKI (OR 0.49; 95% CI 0.28-0.85; p = .01), however, higher risk of major vascular events (OR 7.33; 95% CI 1.80-29.85; p = .005) and higher risk of PPI (OR 2.96; 95% CI 1.80-4.85; p < .001). No statistically significant difference was observed for myocardial infarction and stroke between the groups. In the follow-up analyses, we observed a higher risk of mortality (HR 1.64, 95% CI 1.36-1.96, p < .001) and MACCE with TAVI plus PCI (HR 1.35 (95% CI 1.08-1.69, p = .009).
Conclusion: Patients who undergo TAVI plus PCI (in comparison with SAVR plus CABG) initially experience lower rates of in-hospital death and AKI; however, they experience significantly lower survival rates and more MACCE at 5-year follow up. Structural heart surgeons and interventional cardiologists should consider these aspects when referring patients for one approach or the other.
