Routine revascularization with percutaneous coronary intervention in patients with coronary artery disease undergoing transcatheter aortic valve implantation - the third nordic aortic valve intervention trial - NOTION-3

Multiparametric Outcome Assessment After Transcatheter Aortic Valve Implantation-A Systematic Review

Backround/Objectives: Aortic stenosis (AS) is the most commonly acquired valvular disorder. Patient risk stratification and the development of an accurate and reliable tool are crucial in identifying suitable candidates for TAVI. The present review summarized the current state of knowledge on the influence of selected factors on the outcomes and course of patients with AS undergoing transcatheter aortic valve implantation (TAVI). Methods: The inclusion criteria for the present systematic review were as follows: (1) studies indexed in the medical databases PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, and Scopus; (2) full-text articles available in English; (3) papers published between 2013 and 2023; and (4) addressing the topic of assessing the impact of factors on the outcomes of patients with aortic stenosis undergoing TAVI. This review used PRISMA 2020 reporting guidelines for systematic reviews and meta-analyses. Results: One hundred and thirty-two studies were eligible for this review. The available studies showed an association of psychosocial and socioeconomic factors, valve parameters, comorbidities, clinical factors, treatment-related factors, biomarkers, and treatment methods with the outcomes of patients with AS undergoing TAVI. Conclusions: Given the conflicting results obtained regarding the impact of right ventricular dysfunction, paravalvular leaks, and treatment method on the mortality of patients undergoing aortic valve implantation, further research in these areas is needed. In view of the researchers' differing views on some of the factors affecting patient outcomes after TAVI, further analysis is needed to develop a new tool for assessing predictive outcomes in AS patients. This study is registered at PROSPERO (CRD42024612752).

Coronary Artery Disease and Severe Aortic Stenosis: Contemporary Treatment Options for Patients Undergoing Transcatheter Aortic Valve Implantation

Approximately 50% of individuals eligible for transcatheter aortic valve implantation (TAVI) have coronary artery disease (CAD). The influence of CAD, both its prevalence and severity, on post-TAVI clinical results has yielded conflicting findings. Recent research has shown positive results for the use of computed tomography angiography and functional percutaneous evaluation of coronary lesions in the pre-TAVI assessment, besides the classic coronary angiography. As we anticipate the outcomes of current randomized studies, it has become common practice to perform invasive revascularization on TAVI patients with obstructive CAD. Furthermore, there is a lack of comprehensive data about the occurrence, features, and treatment of coronary incidents after TAVI. There is also growing concern about the possible difficulties in accessing the coronary arteries in patients who need coronary angiography with or without intervention after TAVI. This review presents a comprehensive analysis of the contemporary treatment options of CAD in patients undergoing TAVI. In this context, it examines the incidence of CAD in TAVI candidates; its clinical significance; the assessment and management of CAD before, concomitant, and after the procedure, including patients' unresolved concerns; and possible future aspects.

PCI in Patients Undergoing Transcatheter Aortic-Valve Implantation

BACKGROUND

The benefit of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease and severe aortic stenosis who are undergoing transcatheter aortic-valve implantation (TAVI) remains unclear.

METHODS

In an international trial, we randomly assigned, in a 1:1 ratio, patients with severe symptomatic aortic stenosis and at least one coronary-artery stenosis with a fractional flow reserve of 0.80 or less or a diameter stenosis of at least 90% either to undergo PCI or to receive conservative treatment, with all patients also undergoing TAVI. The primary end point was a major adverse cardiac event, defined as a composite of death from any cause, myocardial infarction, or urgent revascularization. Safety, including bleeding events and procedural complications, was assessed.

RESULTS

A total of 455 patients underwent randomization: 227 to the PCI group and 228 to the conservative-treatment group. The median age of the patients was 82 years (interquartile range, 78 to 85), and the median Society of Thoracic Surgeons-Predicted Risk of Mortality score (on a scale from 0 to 100%, with higher scores indicating a greater risk of death within 30 days after the procedure) was 3% (interquartile range, 2 to 4). At a median follow-up of 2 years (interquartile range, 1 to 4), a major adverse cardiac event (primary end point) had occurred in 60 patients (26%) in the PCI group and in 81 (36%) in the conservative-treatment group (hazard ratio, 0.71; 95% confidence interval [CI], 0.51 to 0.99; P = 0.04). A bleeding event occurred in 64 patients (28%) in the PCI group and in 45 (20%) in the conservative-treatment group (hazard ratio, 1.51; 95% CI, 1.03 to 2.22). In the PCI group, 7 patients (3%) had PCI procedure-related complications.

CONCLUSIONS

Among patients with coronary artery disease who were undergoing TAVI, PCI was associated with a lower risk of a composite of death from any cause, myocardial infarction, or urgent revascularization at a median follow-up of 2 years than conservative treatment. (Funded by Boston Scientific and the Danish Heart Foundation; NOTION-3 ClinicalTrials.gov number, NCT03058627.).

A randomized comparison of the treatment sequence of percutaneous coronary intervention and transcatheter aortic valve implantation: Rationale and design of the TAVI PCI trial

BACKGROUND

About half of patients with severe aortic stenosis present with concomitant coronary artery disease. The optimal timing of percutaneous coronary intervention (PCI) and transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis and concomitant coronary artery disease remains unknown.

STUDY DESIGN

The TAVI PCI trial is a prospective, international, multicenter, randomized, 2-arm, open-label study planning to enroll a total of 986 patients. It is designed to investigate whether the strategy "angiography-guided complete revascularization after (within 1-45 days) TAVI" is noninferior to the strategy "angiography-guided complete revascularization before (within 1-45 days) TAVI" using the Edwards SAPIEN 3 or 3 Ultra Transcatheter Heart Valve in patients with severe aortic stenosis and concomitant coronary artery disease. Patients are randomized in a 1:1 ratio to one of the 2 treatment strategies. The primary end point is a composite of all-cause death, nonfatal myocardial infarction, ischemia-driven revascularization, rehospitalization (valve- or procedure-related including heart failure), or life-threatening/disabling or major bleeding at 1 year.

CONCLUSIONS

The TAVI PCI trial tests the hypothesis that the strategy "PCI after TAVI" is noninferior to the strategy "PCI before TAVI" in patients with severe aortic stenosis and concomitant coronary artery disease.

Evaluation and management of coronary artery disease in transcatheter aortic valve implantation candidates with severe aortic stenosis and coronary artery disease: technology and techniques

INTRODUCTION

Patients with severe aortic stenosis referred for transcatheter aortic valve implantation (TAVI) often present with concomitant coronary artery disease (CAD). The management of CAD in these patients remains a topic of debate, encompassing the evaluation and timing of percutaneous coronary intervention (PCI).

AREAS COVERED

This review article aims to offer an overview of the role of coronary revascularization in TAVI patients, highlighting the advantages and disadvantages of different strategies: PCI before, concomitant with, and after TAVI. Considering that TAVI indications are expanding and patients with low surgical risk are now being referred for TAVI, the rate of PCI among patients undergoing TAVI is expected to increase. Historically, PCI was performed before TAVI. However, there is now a growing trend to defer PCI until after TAVI.

EXPERT OPINION

It is plausible that in the future, there will be an increase in PCI after TAVI due to several factors: first, multiple studies have shown the safety of TAVI even in patients with severe untreated CAD; second, improvements in TAVI device implantation techniques, such as commissural alignment and patient-specific device selection, have improved access to the coronary arteries post-TAVI.

A randomised multicentre study of angiography- versus physiologyguided percutaneous coronary intervention in patients with coronary artery disease undergoing TAVI: design and rationale of the FAITAVI trial

The treatment of coronary artery disease (CAD) in patients with severe aortic valve stenosis (AVS) eligible for transcatheter aortic valve implantation (TAVI) is not supported by clinical evidence, and the role of physiology over anatomy as well as the timing of coronary intervention are not defined. FAITAVI (ClinicalTrials.gov: NCT03360591) is a nationwide prospective, open-label, multicentre, randomised controlled study comparing the angiography-guided versus the physiology-guided coronary revascularisation strategy in patients with combined significant CAD and severe AVS undergoing TAVI. Significant CAD will be defined as coronary stenosis ≥50%, as assessed by visual estimation in vessels ≥2.5 mm. Physiology will be tested by fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR). The study will be conducted at 15 sites in Italy. In the angiography arm, percutaneous coronary intervention (PCI) will be performed either before TAVI, during the TAVI procedure - before or after the valve implantation - or within 1 month±5 days of the valve implantation, left to the operator's decision. In the physiology arm, FFR and iFR will be performed before TAVI, and PCI will be indicated for FFR ≤0.80, otherwise the intervention will be deferred. In case of borderline values (0.81-0.85), FFR and iFR will be repeated after TAVI, with PCI performed when needed. With a sample size of 320 patients, the study is powered to evaluate the primary endpoint (a composite of death, myocardial infarction, stroke, major bleeding, or ischaemia-driven target vessel revascularisation). TAVI indication, strategy and medical treatment will be the same in both groups. After discharge, patients will be contacted at 1, 6, 12 and 24 months after the procedure to assess their general clinical status, and at 12 months for the occurrence of events included in the primary and secondary endpoints. FAITAVI is the first randomised clinical trial to investigate "optimal" percutaneous coronary intervention associated with TAVI in patients with severe AVS and CAD.

Coronary artery disease and outcomes following transcatheter aortic valve implantation

BACKGROUND

Aortic stenosis is a life-limiting condition for which transcatheter aortic valve implantation (TAVI) is an established therapy. Coronary artery disease (CAD) is frequently found in this patient group and optimal management in these patients remains uncertain.

OBJECTIVES

We sought to examine the association of coexistent CAD on mortality and hospital readmission in patients undergoing TAVI.

METHODS

In this observational cohort study, we examined patients who underwent TAVI and segregated them by the presence of obstructive epicardial CAD. The primary outcome was 3-year mortality with secondary outcomes being readmission for (1) all-causes, (2) a MACE (Major Adverse Cardiovascular Event) composite endpoint and (3) acute coronary syndrome. Subsidiary outcomes included patient angina and breathlessness scores.

RESULTS

898 patients underwent TAVI, of which 488 (54.3%) had unobstructed coronary arteries and 410 (45.7%) had obstructive CAD. Overall, n=298 (33.2%) patients experienced the primary mortality endpoint with no significant difference when stratified according to CAD (n=160 (32.9%) vs n=136 (33.2%), HR 0.98, CI 0.78 to 1.24). After multivariate analysis, the presence of CAD had no effect on the primary outcome (HR 0.98, CI 0.68 to 1.40). There was no significant difference in readmission for any cause (n=181, 37.1% (CAD) vs n=169, 41.2% (no CAD), p=0.23), including no significant difference on readmission for MACE (n=48, 9.8% (CAD) vs n=45, 11.0% (no CAD), p=0.11). CAD at the time of TAVI also did not alter breathlessness or angina scores before/after TAVI (p>0.05).

CONCLUSION

Coexistent CAD had no significant association with mortality, any-cause readmission or symptoms for patients undergoing TAVI in our cohort.

Association Between Polyvascular Disease and Transcatheter Aortic Valve Replacement Outcomes: Insights From the STS/ACC TVT Registry

BACKGROUND

Atherosclerotic cardiovascular disease is highly prevalent in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Polyvascular disease (PVD), defined as involvement of ≥2 vascular beds (VBs), that is, coronary, cerebrovascular, or peripheral, portends a poor prognosis in patients with atherosclerotic cardiovascular disease; however, data on the association of PVD with outcomes of patients undergoing TAVR are limited.

METHODS

The Society of Thoracic Surgeons and the American College of Cardiology Transcatheter Valve Therapy Registry was analyzed to identify patients who underwent TAVR from November 2011 to March 2022. The exposure of interest was PVD. The primary outcome was all-cause mortality. Secondary outcomes included major vascular complications, major/life-threatening bleeding, myocardial infarction, transient ischemic attack/stroke, and valve- and non-valve-related readmissions. Outcomes were assessed at 30 days and 1 year.

RESULTS

Of 443 790 patients who underwent TAVR, PVD was present in 150 823 (34.0%; 111 425 [25.1%] with 2VB-PVD and 39 398 [8.9%] with 3VB-PVD). On multivariable analysis, PVD was associated with increased all-cause mortality at 1 year (hazard ratio, 1.17 [95% CI, 1.14-1.20]). There was an incremental increase in 1-year mortality with an increasing number of VBs involved (no PVD [reference]; 2VB-PVD: hazard ratio, 1.12 [95% CI, 1.09-1.15]: and 3VB-PVD: hazard ratio, 1.31 [95% CI, 1.26-1.36]). Patients with versus without PVD had higher rates of major vascular complications, major/life-threatening bleeding, transient ischemic attack/stroke, and non-valve-related readmissions at 30 days and 1 year.

CONCLUSIONS

PVD is associated with worse outcomes after TAVR, and the risk is highest in patients with 3VB-PVD.