Comparison of outcomes in patients having isolated transcatheter aortic valve implantation versus combined with preprocedural percutaneous coronary intervention

In-Hospital Outcomes of Combined Coronary Revascularization and Transcatheter Aortic Valve Implantation in Inpatient Nationwide Analysis

Transcatheter aortic valve implantation (TAVI) is accepted as an alternative to surgery, but data on combined percutaneous coronary interventions (PCI) and TAVI during the same in-hospital stay are still lacking. Using the national inpatient sample (NIS) database, we identified all TAVI encounters and compared in-hospital outcomes of patients who had TAVI only to patients who had TAVI and PCI. We used multivariable logistic regression analysis to calculate the adjusted odds ratio (aOR). Of 291,810 patient encounters with TAVI, 13,114 (4.5%) had combined PCI during the same index admission. The average age was 79.61 ± 8.61 years in the TAVI-only vs 80.25 ± 8.73 years in the combined TAVI-PCI group. Combined TAVI and PCI was associated with higher in-hospital mortality (4.5% vs 1.8%, aOR: 2.3), stroke (4.7% vs 2.9%, aOR: 1.4), net adverse events (NAE) (20.2% vs 5.7%, aOR: 3.6), major bleeding (40.1% vs 24.3%, aOR: 1.8), vascular complications (10.6% vs 2.5%, aOR: 3.9), acute kidney injury (AKI) (23.3% vs 11.7%, aOR: 2.1), hemodialysis (HD) (4.2% vs 2.4%, aOR: 1.4), postoperative cardiogenic shock (1.2% vs 0.4%, aOR: 2.8), need for mechanical circulatory support (6.9% vs 1%, aOR: 7); p-value < 0.001 for all. The utilization of permanent pacemakers was similar between the groups (9.8% vs 9.2%, aOR: 1; p = 0.6). Combining TAVI and PCI during the same index admission is associated with worse outcomes. The decision to do PCI for patients undergoing TAVI should be individualized and tailored based on the patient's clinical conditions.

Impact of Chronic Coronary Artery Disease and Revascularization Strategy in Patients with Severe Aortic Stenosis Who Underwent Transcatheter Aortic Valve Implantation

The prognostic impact of coronary artery disease (CAD) after transcatheter aortic valve implantation (TAVI) is controversial. The aim of this study is to investigate the impact of CAD and different revascularization strategies on clinical outcomes in patients who underwent TAVI with third generation devices. Patients enrolled in the national observational Observational Study of Effectiveness of SAVR-TAVI Procedures for Severe Aortic Stenosis Treatment II study were stratified according to the presence of CAD (CAD+, n = 1,130) versus no CAD (CAD-, n = 1,505), and compared using a propensity matched analysis. CAD+ group was further stratified according to the revascularization strategy: no revascularization (n = 331), revascularization performed >90 days before index-TAVI (n = 417) and coronary revascularization performed <90 days before index-TAVI or during TAVI (n = 382). In-hospital, 30-day and 1-year clinical outcomes were estimated. The mean age of the overall population was 81.8 years; 54.9% of patients were female. Propensity score matching yielded 813 pairs and their 30-day all-cause mortality was comparable (p = 0.480). Major periprocedural adverse events were also similar between the groups. At 1-year follow-up, the rate of major adverse cardiac and cerebrovascular events (MACCEs) and all-cause mortality were similar between the groups (p = 0.732 and p = 0.633, respectively). Conversely, patients with CAD experienced more often myocardial infarction and need for percutaneous coronary intervention at 1 year (p = 0.007 and p = 0.001, respectively). Neither CAD nor revascularization strategy were independent predictors of 1-year MACCE. About 40% of patients presenting with severe AS and who underwent TAVI had concomitant CAD. The presence of CAD had no impact on all-cause mortality and MACCE 1-year after TAVR. However, CAD carries a higher risk for acute myocardial infarction and need of percutaneous coronary intervention during follow-up.

Trends and outcomes of combined percutaneous (TAVI+PCI) and surgical approach (SAVR+CABG) for patients with aortic valve and coronary artery disease: A National Readmission Database (NRD) analysis

BACKGROUND

In patients with severe aortic stenosis (AS) and concomitant severe coronary artery disease (CAD), the relative merits of a combined percutaneous (transcatheter aortic valve implantation [TAVI] and percutaneous coronary intervention [PCI]] versus surgical approach (surgical aortic valve replacement [SAVR] and coronary artery bypass graft [CABG]) remain unknown.

AIMS

To determine the utility of combined percutaneous versus surgical approaches in patients with severe AS and CAD.

METHODS

The National Readmission Database (NRD) (2015-2019) was queried to identify all cases of TAVI+PCI and SAVR+CABG. The adjusted odds ratios (aOR) of mortality, stroke, and its composite (major adverse cardiovascular events [MACE]) were calculated using a propensity-score matched (PSM) analysis.

RESULTS

A total of 89,314 (5358 TAVI+PCI, 83,956 SAVR+CABG) patients were included in the crude analysis. There was a gradual increase in the utilization of TAVI+PCI from 2016 to 2019 by 2%-4% per year. Using PSM, a subset of 11,361 (5358 TAVI+PCI, 6003 SAVR+CABG) patients with a balanced set of demographics and baseline comorbidities was selected. During index hospitalization, the adjusted odds of MACE (aOR 0.72, 95% confidence interval [CI] 0.62-0.83), and all-cause mortality (aOR 0.68, 95% CI 0.57-0.81) were significantly lower in patients undergoing TAVI+PCI compared with SAVR+CABG. However, patients undergoing TAVI+PCI had a higher incidence of MACE (aOR 1.40, 95% CI 1.05-1.87), and mortality (aOR 1.75, 95% CI 1.22-2.50) at 30-days. The risk of index-admission (aOR 0.82, 95% CI 0.62-1.09) and 30-day (aOR 0.88, 95% CI 0.51-1.51) stroke was similar between the two groups.

CONCLUSION

In selected patients with severe AS and concomitant CAD, a combined percutaneous approach (TAVR+PCI) compared with SAVR+CABG may confer a lower risk of MACE and mortality during index admission but a higher incidence of 30-day complications.

Clinical Outcomes of Transcatheter Aortic Valve Replacement With and Without Percutaneous Coronary Intervention-An Updated Meta-Analysis and Systematic Review

Transcatheter aortic valve replacement (TAVR) is indicated for high-risk patients with severe degenerative aortic stenosis (AS). Given the shared risk factors and coexistence of obstructive coronary artery disease (CAD) and AS, there is inconsistent clinical data regarding potential survival benefits of paired percutaneous coronary intervention (PCI) with TAVR procedures. We performed a literature search using PubMed, Embase, and Cochrane Library from inception through June 2023 assessing the impact of concomitant PCI in patients with obstructive CAD undergoing TAVR. The primary outcomes were 30-day all-cause mortality, 30-day cardiovascular mortality, and 6 months-1 year all-cause mortality. Secondary outcomes included 30-day myocardial infarction, stroke, major bleeding complications, and acute kidney injury (AKI). A total of 11 studies involving 2804 patients were included in the final analysis. Compared to patients undergoing TAVR alone, the TAVR+PCI group showed no significant difference in 30-day all-cause mortality (RR 0.90, CI 0.66, 1.22, P = 0.49), 30-day cardiovascular mortality (RR 0.71 CI 0.44, 1.14, P = 0.16), or 6 months-1 year all-cause mortality (RR 0.94, CI 0.75, 1.18, P = 0.57). Regarding secondary outcomes, 30-day myocardial infarction was higher in the TAVR+PCI group (RR 3.09, CI 1.26, 7.57, P = 0.01), with no significant differences noted in rates of 30-day stroke (RR 1.14, CI 0.56, 2.33, P = 0.72), major bleeding/vascular complications (RR 1.11, CI 0.79, 1.56, P = 0.55), and AKI (RR 1.07, CI 0.75, 1.54, P = 0.71). Concomitant PCI does not confer any mortality benefit in patients with obstructive CAD and high-grade AS undergoing TAVR. Further trials are needed to confirm our findings.

Rotational atherectomy of left main stem immediately after transcatheter aortic valve implantation in a patient with symptomatic severe aortic stenosis and an impaired left ventricular systolic function: a case report

Background

Severe aortic stenosis (AS) and coronary artery disease (CAD) often coexist since they both share the same risk factors and pathophysiology. Patients with severe AS with prohibitive surgical risk are often treated with transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) as a staged or concurrent procedure. Significant calcified CAD and left ventricular (LV) systolic impairment in such patients would add more challenges to the management. A clear consensus on the timing of revascularization of such patients in relation to the TAVI procedure is lacking.

Case summary

Herein, we present an 86-year-old male who presented to a local district hospital with non-ST-segment elevation myocardial infarction (N-STEMI) and decompensated heart failure. His transthoracic echocardiography showed moderate LV systolic impairment with low-flow severe AS. He was initially treated with dual anti-platelet and diuretic therapy and subsequently underwent coronary angiography that revealed severe calcified shelf-like left main stem (LMS) and moderate left anterior descending (LAD) disease. He was successfully treated with TAVI and rotational atherectomy (RA)-assisted PCI to LMS and LAD in the same setting.

Conclusion

There is limited evidence on effective strategies to tackle high-risk angioplasty with concurrent TAVI in patients with impaired LV function. We performed TAVI and RA to LMS and LAD in the same setting using no mechanical circulatory support (MCS). Management strategies should be individualized to highly selected patients taking into account LMS involvement, calcium modulation strategies, haemodynamic instability, or cardiogenic shock and whether MCS is needed.

Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions in collaboration with the ESC Working Group on Cardiovascular Surgery

Significant coronary artery disease (CAD) is a frequent finding in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), and the management of these two conditions becomes of particular importance with the extension of the procedure to younger and lower-risk patients. Yet, the preprocedural diagnostic evaluation and the indications for treatment of significant CAD in TAVI candidates remain a matter of debate. In this clinical consensus statement, a group of experts from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery aims to review the available evidence on the topic and proposes a rationale for the diagnostic evaluation and indications for percutaneous revascularisation of CAD in patients with severe aortic stenosis undergoing transcatheter treatment. Moreover, it also focuses on commissural alignment of transcatheter heart valves and coronary re-access after TAVI and redo-TAVI.

Clinical impact of the extent of jeopardized myocardium in patients undergoing transcatheter aortic valve intervention

INTRODUCTION AND OBJECTIVES

Coronary artery disease (CAD) is found in 30%-50% of patients with severe aortic stenosis (AS) undergoing treatment. The best management of CAD in AS patients undergoing transcatheter aortic valve implantation (TAVI) is still unclear. We investigated the clinical impact of the extent of jeopardized myocardium in patients with concomitant CAD and severe AS treated by TAVI.

METHODS

Consecutive patients who underwent TAVI procedures at our hospital were identified. In the presence of CAD, the myocardium jeopardized before TAVI was graded using the British Cardiovascular Intervention Society (BCIS) jeopardy score (JS). The study population was divided in 3 groups: patients without concomitant CAD (no-CAD), patients with CAD and BCIS-JS ≤ 4 (CAD BCIS-JS ≤ 4) and patients with concomitant CAD and BCIS-JS> 4 (CAD BCIS-JS> 4). The primary study endpoint was major adverse cardiovascular and cerebrovascular events (MACCE).

RESULTS

A total of 403 patients entered the study: 223 no-CAD, 94 CAD BCIS-JS ≤ 4 and 86 CAD BCIS-JS> 4. At> 3 months of follow-up [range 104-3296 days], patients without CAD and CAD patients with BCIS-JS ≤ 4 had better survival free from MACCE compared with those with less extensive revascularization (BCIS-JS> 4) (P=.049). This result was driven by a significant reduction in death (P=.031). On multivariate analysis, residual BCIS-JS ≤ 4 and NYHA class III-IV independently predicted MACCE.

CONCLUSIONS

In patients with concomitant CAD and severe AS, the extent of jeopardized myocardium before TAVI impacts on clinical outcomes.

Catheter versus surgical approach for the management of concomitant aortic stenosis and coronary artery disease: An inverse probability treatment weighting analysis

BACKGROUND

Two therapeutic strategies are available when aortic stenosis and coronary artery disease coexist: a transcatheter approach, with percutaneous coronary intervention followed by transcatheter aortic valve replacement; and a surgical approach, consisting of surgical aortic valve replacement combined with coronary artery bypass graft.

AIM

We sought to compare the outcomes of these two strategies.

METHODS

The study population consisted of 241 patients who benefited from aortic valve replacement and coronary revascularization (transcatheter, n=150; surgery, n=91).

RESULTS

Patients in the transcatheter population were older (83.5 vs. 71.8years; P<0.001) and had a higher Logistic EuroSCORE (11.1% vs. 5.7%; P<0.001). At 30days postprocedure, patients who had surgery exhibited more life-threatening bleedings (12.1% vs 4.5%; P=0.034), acute kidney injury (12.1% vs. 1.3%; P<0.001) and atrial fibrillation (55.6% vs. 8.7%; P<0.001). After a median follow-up of 27months, the risk of major adverse cardiovascular or cerebrovascular events did not differ significantly between the two strategies (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.97-2.04; P=0.07), whereas estimated glomerular filtration rate<60mL/min (HR 2.22, 95% CI 1.58-3.12; P<0.001), peripheral artery disease (HR 2.00, 95% CI 1.37-2.91; P<0.001) and left ventricular ejection fraction<50% (HR 1.69, 95% CI 1.12-2.55; P=0.012) were associated with a negative prognosis.

CONCLUSIONS

In our study, patients with aortic stenosis and coronary artery disease treated by catheter were older and had a higher co-morbidity burden than those treated by surgery. The surgical strategy was associated with a higher rate of 30-day complications, but long-term outcomes were similar between the two strategies.

Management of coronary artery disease in patients with aortic stenosis

Aortic stenosis (AS) is the most common valvular heart disorder in the elderly population. As a result of the shared pathophysiological processes, AS frequently coexists with coronary artery disease (CAD). These patients have traditionally been managed through surgical aortic valve replacement (SAVR) and coronary artery bypass grafting. However, increasing body of evidence supports transcatheter aortic valve implantation (TAVI) as an alternative treatment for severe AS across the spectrum of operative risk. This has created the potential for treating AS and concurrent CAD completely percutaneously. In this review we consider the evidence guiding the optimal management of patients with severe AS and CAD. While invasive coronary angiography plays a central role in detecting CAD in patients with AS undergoing surgery or TAVI, the benefits of complementary functional assessment of coronary stenosis in the context of AS have not been fully established. Although the indications for revascularisation of significant proximal CAD in SAVR patients have not recently changed, routine revascularisation of all significant CAD before TAVI in patients with minimal angina is not supported by the latest evidence. Several ongoing trials will provide new insights into physiology-guided revascularisation in TAVI recipients. The role of the heart team remains essential in this complex patient group, and if revascularisation is being considered careful evaluation of clinical, anatomical and procedural factors is essential for individualised decision-making.

Optimal timing for percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation

BACKGROUND

The best timing to perform percutaneous coronary interventions (PCI) in patients undergoing TAVI is unknown. Most PCI are performed before TAVI, because of concerns about potential ischemic complications during valve implantation. In this study we aimed to compare short-and long-term outcomes of patients undergoing PCI before or after TAVI.

METHODS

Patients undergoing TAVI and PCI from 2010 to 2021 were analyzed. PCI was defined as high-risk when involving unprotected left main, proximal left anterior descending, proximal dominant right coronary artery or 3-vessel disease. The primary endpoint was the cumulative incidence of any TAVI procedural complication and in-hospital adverse events (VARC-3 criteria).

RESULTS

Out of 1162 patients, 144 underwent PCI, 68% after TAVI, 78.4% of which were at high-risk. The primary endpoint occurred in 28.4% of patients in PCI pre-TAVI group vs 21.4% in PCI post-TAVI group (p = 0.403) and in 34.4% vs 17.3% of patients respectively among high-risk patients (p = 0.075). A higher rate of stroke was observed in the PCI pre-TAVI group regardless of the PCI complexity (6.5% vs 0.0%, p = 0.031; 9.3% vs 0.0% p = 0.025 in the high-risk group). At 24 months, MACCE-free survival was lower in patients who underwent PCI before TAVI (84.4% vs 97.9%, adjusted HR 10.16, 95% CI 1.19-86.57, p = 0.019; and 84.4% vs 97.3%, adjusted HR 7.34 95% CI 0.78-62.28 p = 0.082 in the high-risk group).

CONCLUSIONS

PCI performed after TAVI does not expose patients to higher risks of peri-procedural hazards and provides a trend towards favourable clinical outcome at mid-to-long term.

Revascularization in the Transcatheter Aortic Valve Replacement Population

Transcatheter aortic valve replacement (TAVR) is a standard treatment option for patients with severe aortic stenosis. Management of concomitant coronary artery disease (CAD) in these patients remains controversial with no randomized clinical trials to guide decision making in this cohort. The role of CAD in TAVR has been difficult to evaluate given the current heterogeneity in defining CAD, and the used methods to assess CAD. Subsequently, the role of coronary revascularization remains individualized and assessed on a case-by-case basis by the heart team. In this article, the authors discuss the rationale and prognostic role of CAD in patients undergoing TAVR.

Improvement of Pulmonary Function in Heart Failure Patients with Restrictive Patterns Undergoing Transcatheter Aortic Valve Replacement

Background

This study aimed to investigate the improvement of pulmonary function in heart failure patients with restrictive patterns undergoing transcatheter aortic valve replacement (TAVR).

Methods

A total of 80 patients with heart failure and restrictive patterns undergoing TAVR due to severe aortic stenosis were included in this study. Spirometry and gas diffusion were assessed before and 4–6 months after TAVR. Pre- and post-TAVR measures were compared using paired t-tests.

Results

Spirometry demonstrated increased absolute and percentage predicted total lung capacity (TLC), forced vital capacity (FVC), residual volume (RV), forced expiratory volume in the first second (FEV1), and forced vital capacity (FVC). FEV1/FVC decreased due to a pronounced increase in FVC. Additionally, the diffusing capacity for carbon monoxide (DLCO) increased significantly.

Conclusion

Pulmonary function improves in heart failure patients with restrictive patterns undergoing TAVR.

Role of coronary angiogram before transcatheter aortic valve implantation

BACKGROUND

Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation (TAVI). Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes, challenging the clinical value of routine coronary angiogram (CA).

AIM

To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.

METHODS

This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI. A selective approach for performing CA tailored to patient clinical need was developed. Clinical outcomes were compared based on whether patients underwent CA. The primary endpoint was a composite of all-cause mortality, myocardial infraction, repeat CA, and re-admission with heart failure.

RESULTS

Of 348 patients (average age 81 ± 7 and 57% male) were included with a median follow up of 19 (9-31) mo. One hundred and fifty-four (44%) patients, underwent CA before TAVI procedure. Patients who underwent CA were more likely to have previous myocardial infarction (MI) and previous percutaneous revascularisation. The primary endpoint was comparable between the two group (22.6% vs 22.2%; hazard ratio 1.05, 95%CI: 0.67-1.64, P = 0.82). Patients who had CA were less likely to be readmitted with heart failure (P = 0.022), but more likely to have repeat CA (P = 0.002) and MI (P = 0.007). In those who underwent CA, the presence of flow limiting lesions did not affect the incidence of primary endpoint, or its components, except for increased rate of repeat CA.

CONCLUSION

Selective CA is a feasible and safe approach. The clinical value of routine CA should be challenged in future randomised trials

Contrast-Induced Nephropathy in Patients Undergoing Staged Versus Concomitant Transcatheter Aortic Valve Implantation and Coronary Procedures

Background

The impact of staged versus concomitant coronary procedures on renal function in patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) remains unclear.

Methods and Results

Three‐hundred thirty‐nine patients undergoing coronary procedures and TAVI as a staged strategy (160, 47.2%) or concomitant strategy (179, 52.8%) were retrospectively analyzed. Contrast‐induced acute kidney injury (CI‐AKI) occurred in 49 patients in the staged strategy group (30.6%) and in 18 patients (10.1%) in the concomitant strategy group (P<0.001). Among the staged strategy group, 25 (15.6%) patients developed CI‐AKI after coronary angiography or percutaneous coronary intervention, 17 (10.6%) after TAVI, and 7 (4.3%) after both the procedures. Staged strategy was associated with a higher risk of CI‐AKI (odds ratio, 3.948; P<0.001) after adjustment for multiple confounders and regardless of the baseline renal function (P for interaction=0.4) when compared with the concomitant strategy. At a median follow‐up of 24.0 months (3.0–35.3), CI‐AKI was not associated with sustained renal injury (P=0.794), irrespective of the adopted strategy. The concomitant strategy did not impact the overall early safety at 30 days follow‐up after TAVI compared to the staged strategy (P=0.609).

Conclusions

Performing coronary procedures with a staged strategy before TAVI was associated with a higher risk of CI‐AKI compared with a concomitant strategy. Moreover, a concomitant strategy did not increase the risk of procedure‐related complications.

Percutaneous Coronary Intervention in Transcatheter Aortic Valve Implantation Patients: Overview and Practical Management

Coronary artery disease (CAD) is present in 40-75% of patients undergoing transcatheter aortic valve implantation (TAVI) for severe symptomatic aortic stenosis. Currently, the indication for TAVI is expanding toward younger patients at lower surgical risk. Given the progressive nature of CAD, the necessity for coronary angiography (CA), including percutaneous coronary intervention (PCI), will subsequently increase as in the future TAVI patients will be younger and have a longer life expectancy. Data on the impact of PCI in patients with severe CAD scheduled for TAVI are controversial, and although European and US guidelines recommend PCI before TAVI, the optimal timing for PCI remains unclear due to a lack of evidence. Depending on the valve type, position, and axial alignment of the implanted device, CA and/or PCI after TAVI can be challenging. Hence, every interventionalist should be familiar with the different types of transcatheter heart valves and their characteristics and technical issues that can arise during invasive coronary procedures. This review provides an overview of current data regarding the prevalence and clinical implications of CAD and PCI in TAVI patients and includes useful guidance for practical management in the clinical routine.

Outcomes of concomitant percutaneous coronary interventions and transcatheter aortic valve replacement

Introduction

Coronary artery disease is a common diagnosis among patients undergoing transcatheter aortic valve replacement (TAVR). The treatment and timing of percutaneous coronary intervention (PCI) remain controversial. We sought to compare in-hospital periprocedural outcomes of combined TAVR and PCI during the same index hospitalization versus the isolated TAVR procedure.

Material and methods

The study population was extracted from the 2016 Nationwide Readmissions Data (NRD) using International Classification of Diseases, tenth edition, clinical modifications/procedure coding system codes for TAVR, coronary PCI, and post-procedural complications. Study endpoints included in-hospital all-cause mortality, length of index hospital stay, cardiogenic shock, need for mechanical circulatory support (MCS) devices, mechanical complications of prosthetic valve, paravalvular leak (PVL), acute kidney injury (AKI), bleeding and total hospital charges. Propensity matching was used to adjust for baseline characteristics.

Results

There were 23,604 TAVRs in the 2016 NRD, of which 852 were combined with PCI during the same index hospitalization. Mean age was 80.5 years and 45.9% were female. In comparison to isolated TAVR, TAVR-PCI was associated with higher in-hospital all-cause mortality (4.5% vs. 1.7%, p < 0.01), longer length of stay (10.5 vs. 5.4 days, p < 0.01), and higher incidence of cardiogenic shock (9.4% vs. 2.1%, p < 0.01), use of MCS devices (6.8% vs. 0.7%, p < 0.01), mechanical complications of prosthetic valve (6.8% vs. 0.7%, p < 0.01), PVL (0.9% vs. 0.4%, p = 0.01), AKI (25.5% vs. 11.5%, p < 0.01), bleeding (25.2% vs. 18.1%, p < 0.01), and total hospital charges ($354,725 vs. $220474, p < 0.01).

Conclusions

In comparison to isolated TAVR, combined TAVR-PCI was associated with a higher incidence of in-hospital morbidity and mortality. The association and mechanism of increased mortality warrant further study.

Short-and-Long-Term Outcomes after Coronary Rotational Atherectomy in Patients Treated with Trans-Catheter Aortic Valve Implantation

Background. Coronary artery disease (CAD) is a common finding among patients undergoing trans-catheter aortic valve implantation (TAVI), who often present severely calcified coronary lesions. Evidence is scarce about the use of rotational atherectomy (RA) in this setting, in particular regarding long-term outcome. Methods. RA was performed on severely calcified coronary lesions concomitant with TAVI in a consecutive series of patients treated between 2010 and 2020. Immediate and long-term clinical outcomes are reported. Results. A concomitant CAD (coronary stenosis visually > 50%) was observed in 402/845 (47.6%) consecutive patients undergoing TAVI at the University Hospital of Verona. Angioplasty was performed in 104 patients (12.3%). Among these, 19 patients (18.3%, 20 coronary arteries), were treated with RA after TAVI: 10 after implantation of a balloon-expandable trans-catheter valve and 9 after a self-expandable valve. All procedures were successful. Hypotension occurred in 3 patients (15.8%), with rapid recovery after the procedure; CI-AKI (contrast-induced acute kidney injury) in 3 patients (15.8%), of which two recovered within discharge. At a median follow-up of 21.5 months (Q1–3: 6–36) event free survival was 83.3%. Only one patient suffered a target vessel failure >2 years after RA. Neither stroke nor peri-procedural infarctions were detected. Conclusions. RA concomitant with TAVI was feasible and safe in patients treated with implantation of either self-expandable, or balloon-expandable trans-catheter aortic valves. Long-term clinical events related to the coronary procedure were extremely infrequent and the survival rate at median follow-up of 21.5 months was 83.3%.

ROTAVI: simultaneous left main rotablation and transcutaneous aortic valve implantation in calcified coronaries and severe aortic stenosis - a case report

Background

There is a high incidence of calcified coronary artery disease in patients with severe valvular aortic stenosis (AS). With transcutaneous aortic valve replacement (TAVR) as one of the promising options for severe AS in high and intermediate surgical risk patients; we will encounter more and more patients who will require both complex percutaneous coronary intervention (PCI) with rotablation (RA) and TAVR. The timing of PCI in patients undergoing TAVR; however remains indecisive. Due to the complexity of procedures and the risks involved, very few cases of concomitant TAVR and coronary RA have been reported so far.

Case summary

Seventy-five years old high surgical risk female had severe AS with calcified left main (LM) distal and ostial left anterior descending (LAD) artery lesion. Successful PCI with RA to LM-LAD lesion was done followed by uneventful transfemoral TAVR in the same setting.

Discussion

This is probably one of the very few cases reported where PCI to LM with RA and TAVR was done successfully in the same setting. Since the calcified lesion was focal and left ventricular ejection fraction of the patient was normal, we went ahead with PCI without prior balloon dilatation of aortic valve (BAV) which was a deviation from the prior reported cases, where BAV was performed prior to complex PCI to improve the cardiac output. We herein discuss our case and thoughts about concomitant complex PCI and TAVR.

Transcatheter aortic valve implantation versus surgical aortic valve replacement during the COVID-19 pandemic-Current practice and concerns

COVID-19 has had a dramatic impact on the provision of healthcare. COVID-19 can manifest with cardiac and thrombotic presentations. Additionally, patients with cardiovascular comorbidities are at an increased risk of adverse outcomes related to COVID-19 infection. This in turn has led to a significant reduction in the provision of cardiac surgery with alternative management options utilized to address patients with significant disease. In terms of aortic valve disease, transcatheter aortic valve implantation (TAVI) provides advantages over surgical aortic valve replacement in with a lower burden on healthcare resources. COVID-19 also resulted in changes in management strategies and as such TAVI is now being considered in younger- and low-risk patients. However, long term data with regard to TAVI is still unknown, and the use in patient groups that have been excluded in the large pivotal studies that established TAVI as an alternative to surgery has raised specific concerns in the use of TAVI as the preferred treatment choice. With the long term ramification unknown, it is essential that decisions are made with caution.

Balloon aortic valvuloplasty as a palliative treatment in patients with severe aortic stenosis and limited life expectancy: a single center experience

Whether balloon aortic valvuloplasty (BAV) may provide an effective palliation in symptomatic high-risk patients is uncertain. Therefore, we aimed to evaluate outcomes in symptomatic high-risk patients with severe aortic stenosis (AS), who underwent BAV. All-cause mortality and length of hospitalization for heart failure (HF) up to death or to 1-year follow up were collected after BAV. One hundred thirty-two (132) patients (62% women), mean age 85±7 years, underwent BAV with a substantial reduction of the peak-to-peak aortic gradient from 53±21 to 29±15 mmHg (p<0.001). The median of days of HF hospitalization prior to BAV was 9 (0-19), and decreased after BAV to 0 (0-9), p<0.001. During 1-year follow-up patients with untreated CAD (85, 64%) had a higher mortality compared to patients with insignificant/treated CAD (47, 36%): 1-year survival: 45±7% vs. 66± 7%; p=0.02. After adjustment for STS risk score and severity of residual AS, patients with untreated CAD remained at higher risk of mortality (adjusted HR 1.74 [1.01-2.91]; p=0.04). Thus, in this series of symptomatic high-risk patients, BAV was associated with a significant reduction in aortic valve gradient and hospitalization time for HF post-BAV. In patients with significant CAD, percutaneous intervention might be considered in order to improve survival.

Assessment and management of coronary artery disease in patients undergoing transcatheter aortic valve replacement

PURPOSE OF REVIEW

Coronary artery disease (CAD) is commonly observed in patients undergoing transcatheter aortic valve replacement (TAVR). Significant variability exists across institutions for strategies used for CAD diagnosis and its management. The heart team often relies upon traditional practice patterns and the decision for revascularization by percutaneous coronary intervention (PCI) is influenced by patient, angiographic, operator, and system-related factors.

RECENT FINDINGS

Contemporary coronary tomography angiography (CTA) shows significant promise for detection of clinically important CAD and preliminary data support CTA use for TAVR patients. The prognostic implications of CAD in a TAVR population remain unclear with studies showing conflicting data for the benefits of PCI. Recent trials show that medical management is an effective initial treatment strategy for stable CAD, a finding likely also applicable for asymptomatic and stable TAVR patients. In addition, PCI performed pre-TAVR, concomitant with TAVR or after TAVR has been shown to produce similar outcomes. Dual antiplatelet therapy (DAPT) is mandated after PCI but associated with increased risk of bleeding in TAVR population with accumulating evidence for single antiplatelet therapy (SAPT) post-TAVR unless DAPT or anticoagulation is indicated for another reason.

SUMMARY

Although coronary angiography remains the predominant modality for CAD assessment, CTA is increasingly being used in TAVR patients. There is limited evidence to guide CAD management in TAVR patients with significant variability in practice patterns. Medical therapy is recommended for asymptomatic and stable CAD patients with applicability for TAVR population. Despite prior concerns, recent studies suggest successful coronary access post-TAVR and similar outcomes for PCI offered pre-TAVR, concomitant with TAVR and post-TAVR settings. Safety of DAPT should be an important consideration for PCI in TAVR patients. Ongoing studies will determine the preferred testing for CAD diagnosis, benefit of revascularization, timing of PCI, and optimum antithrombotic therapy for TAVR populations.

Management of Coronary Artery Disease in the Setting of Transcatheter Aortic Valve Replacement

Aortic stenosis and coronary artery disease (CAD) frequently co-exist, as they share a common pathophysiology and risk factors. Due to lack of randomised controlled trials (RCTs) and exclusion of significant CAD in transcatheter aortic valve replacement (TAVR) trials, the optimal method of revascularisation of CAD in patients undergoing TAVR remains unknown. Observational studies and meta-analyses have shown varied results in outcomes for patients with CAD undergoing TAVR, and no significant difference in post-TAVR outcomes in patients who underwent revascularisation either prior to or during TAVR versus those who did not. However, some observational studies have shown that patients with lower residual SYNTAX score (rSS) post-revascularisation have better outcomes post-TAVR compared to those with higher rSS. RCTs are needed to clearly understand whether revascularisation is beneficial in these patients. Until then, management of CAD in patients undergoing TAVR must be individualised based on discussion with the heart team.

Meta-Analysis Comparing Outcomes in Patients Undergoing Transcatheter Aortic Valve Implantation With Versus Without Percutaneous Coronary Intervention

Patients having transcatheter aortic valve implantation (TAVI) routinely undergo coronary angiography before the procedure to define the coronary anatomy and to evaluate the extend of coronary artery disease (CAD). Whether percutaneous coronary intervention (PCI) prior/concomitant with TAVI confers any additional clinical benefit in patients with CAD remains unclear. Literature search was performed using Medline, Embase, Google Scholar, and Scopus from inception of these databases till April 2019. Included outcomes were 30-day all-cause mortality, stroke, myocardial infarction (MI), acute kidney injury, and 1-year mortality. The main summary estimate was random effects odds ratio (OR) with 95% confidence intervals (CIs). Eleven cohort studies enrolling 5,580 patients (mean age 82.4 years and 52.6% females) were included. Our study found no difference in effect estimates for 30-day all-cause mortality (OR 1.30 [0.85 to 1.98], p = 0.22, I² = 37.5%), stroke (OR 0.7 (0.36 to 1.45), p = 0.36, I² = 32.8%), MI (OR 2.71 [0.55 to 12.23], p = 0.22, I² = 41.3%), acute kidney injury (OR 0.7 [0.46 to 1.06], p = 0.08, I² = 14.4%) and 1-year all-cause mortality (OR 1.19 [0.92 to 1.52], p = 0.18, I² = 0.0%) in patients who underwent TAVI with and without PCI. In conclusion, our analysis indicates that PCI with TAVI in patients with severe aortic stenosis and concomitant CAD grants no additional clinical advantage in terms of patient important clinical outcomes. Further randomized studies are needed to better delineate the clinical practice for myocardial revascularization in patients receiving transcatheter therapy for aortic valve disease.

Transcatheter aortic valve replacement- management of patients with significant coronary artery disease undergoing aortic valve interventions: surgical compared to catheter-based approaches in hybrid procedures

Background

Coronary artery disease (CAD) is associated with poorer outcomes after aortic valve replacement (AVR). For high-risk patients with complex CAD, combined transcatheter aortic valve replacement (TAVR) plus off-pump/minimally-invasive coronary artery bypass (OPCAB/MIDCAB) has been proposed.

Methods

A prospective registry analysis was performed to compare the characteristics and outcomes of patients undergoing TAVR+OP/MIDCAB with those undergoing TAVR plus percutaneous coronary intervention (PCI) and surgical AVR plus coronary artery bypass grafting (CABG) between 2008 and 2015 at a single site in Germany.

Results

464 patients underwent SAVR+CABG, 50 underwent TAVR+OP/MIDCAB, and 112 underwent TAVR+PCI. The mean ages (p < 0.001) and logistic EuroSCOREs (p < 0.001) were similarly higher in TAVR+OP/MIDCAB and TAVR+PCI patients compared to SAVR+CABG patients. Prior cardiac surgery was more common in TAVR+PCI than in TAVR+OP/MIDCAB and SAVR+CABG patients (p < 0.001). Procedural times were shortest (p < 0.001), creatine kinase (muscle brain) levels least elevated (p < 0.001), pericardial tamponade least common (p = 0.027), and length of hospital stay shortest (p = 0.011) in TAVR+PCI, followed by TAVR+OP/MIDCAB and SAVR+CABG patients. In-hospital mortality was highest for TAVR+OP/MIDCAB patients (18.0%) with comparable rates for TAVR+PCI and SAVR+CABG groups (9.0 and 6.9%; p = 0.009). Mortality by 12 months was more probable after TAVR+OP/MIDCAB (HR: 2.17, p = 0.002) and TAVR/PCI (HR: 1.63, p = 0.010) than after SAVR+CABG, with the same true of rehospitalisation (HR: 2.39, p = 0.003 and HR: 1.63, p = 0.033).

Conclusions

TAVR+OP/MIDCAB patients share many characteristics with TAVR+PCI patients, with only slightly poorer long-term outcomes. In patients ineligible for SAVR+CABG and TAVR+PCI, hybrid interventions are reasonable second-line options.

Electronic supplementary material

The online version of this article (10.1186/s12872-019-1087-2) contains supplementary material, which is available to authorized users.

Impact of residual coronary atherosclerosis on transfemoral transcatheter aortic valve replacement

OBJECTIVES

This study reports on the clinical effects of complete vs incompletely revascularized coronary artery disease on transcatheter aortic valve replacement (TAVR).

BACKGROUND

There is a high prevalence of active coronary artery disease (CAD) in patients undergoing TAVR but preemptive revascularization remains controversial.

METHODS

Patients were categorized into three cohorts: complete revascularization (CR), incomplete revascularization of a major epicardial artery (IR Major), and incomplete revascularization of a minor epicardial artery only (IR Minor). When feasible, SYNTAX scoring was performed for exploratory analysis. Analyses were performed using Cox proportional hazard models and Kaplan-Meier method.

RESULTS

A total of 323 patients with active CAD were included. Adjusted outcomes showed that patients with IR Major had increased incidence of acute myocardial infarction (AMI) or revascularization compared with those in the CR cohort (HR 3.72, P = 0.048). No difference was noted in all-cause mortality or all-cause readmission rates. Exploratory secondary analysis with residual SYNTAX scores showed a significant interaction between disease burden and AMI/revascularization, as well as all-cause readmission. All-cause mortality remained unaffected based on residual SYNTAX scores.

CONCLUSIONS

This is a retrospective single-center study reporting on pre-TAVR revascularization outcomes in patients with active CAD. In this analysis, we found that patients undergoing TAVR benefited from achieving complete revascularization to abate future incidence of AMI/revascularization. Despite this finding, all-cause mortality remained unaffected. Future efforts should focus on the role of functional assessment of the coronaries, as well as the long-term effects of complete revascularization in a larger patient cohort.

To revascularize or not before transcatheter aortic valve implantation?

Concomitant coronary artery disease (CAD) and aortic stenosis occur in approximately 60-75% of patients referred for surgical or transcatheter aortic valve replacement (TAVR). Current guidelines support simultaneous surgical aortic valve replacement and bypass surgery with a class IIa recommendation, based on observational, non-randomized data. With the inception of TAVR, this strategy has been challenged, as observational studies have not shown significant outcome differences in patients with and without CAD treated with TAVR. Performing percutaneous coronary intervention (PCI) in patients with aortic stenosis is safe, but the indication and timing remain controversial. Complete revascularization before TAVR with low residual Syntax score (<8) may be considered in selected cases with extensive, proximal, and severe CAD to improve outcomes. PCI before TAVR may require less contrast and reduce the risk of acute kidney injury, but uninterrupted dual antiplatelet therapy may increase the risk of bleeding during TAVR. Combined PCI and TAVR can be considered for unstable patients with simple lesions or ostial lesions, with risk of coronary occlusion after deployment of the transcatheter heart valve. PCI after TAVR may be considered in patients who remain symptomatic with significant residual ischemia despite optimal medical therapy. In the near future, it is expected that randomized clinical trials will further clarify the indications and role of revascularization in patients undergoing TAVR. In this article we provide an extensive review on the management of CAD in TAVR candidates, including additional considerations on technical aspects, device selection, and adjunctive pharmacological therapies.

Coronary Artery Disease and Transcatheter Aortic Valve Replacement: When to Intervene

"In patients with coronary artery disease undergoing transcatheter aortic valve replacement (TAVR), the decision of whether to revascularize, which lesions to revascularize, and the optimal timing of revascularization remains controversial. The sequence of revascularization should be made on a case-by-case basis. Pre-TAVR revascularization (staged or simultaneous with TAVR) is preferred due to unobstructed access to coronary ostia and is important to consider especially in cases in which long self-expanding valves are used. In patients who are hemodynamically compromised, the valve should be addressed first, as the most important cause of mortality is heart/multiorgan failure."

Routine CT angiography to detect severe coronary artery disease prior to transcatheter aortic valve replacement

Patients undergoing TAVR undergo routine CT angiography (CTA) to assess aorto-iliac pathology and annular dimensions. While coronary CTA may exclude severe CAD in younger patients, its efficacy in defining CAD severity prior to TAVR may be limited. We retrospectively studied 50 consecutive patients undergoing both invasive coronary angiography (ICA) and routine pre-TAVR CTA. Severe CAD was defined as ≥50% stenosis by quantitative coronary angiography and compared to a blinded CTA visual estimation of ≥50% stenosis. The analysis was confined to four segments: left main and three proximal to mid major coronaries to maximize myocardial territory at risk. Coronary assessment was performed using standard reconstructed ECG phases from pre-TAVR chest CTA on a Philips 256 iCT scanner. Nearly ¾ of patients were ≥75 years old, 57% were female, half were diabetic and 45% had prior PCI. By ICA, 49% had significant coronary calcification. The incidence of severe proximal to mid vessel CAD by ICA was 39%. Similarly, a third of patients required PCI prior to TAVR. CTA was unable to exclude severe proximal to mid vessel CAD in 88% of patients in all four segments: non-diagnostic CTA readings were mainly due to calcification (60%) or motion artifact (28%). Non-diagnostic coronary CTA readings ranged from 25 to 72% according to segment analyzed: only the left main segment had diagnostic quality CTA in the majority of patients (p < 0.01). PCI is performed frequently prior to TAVR based upon invasive coronary angiographic assessment. Routine chest CTA algorithms do not provide adequate diagnostic information to exclude severe CAD, primarily due to severe coronary calcification in the TAVR population.

Timing and Outcomes of PCI in the TAVR Era

PURPOSE OF REVIEW

Transcatheter aortic valve replacement (TAVR) has become an established therapy for patients with symptomatic severe aortic stenosis (AS). As the number of patients referred for TAVR increases, so does the prevalence of untreated obstructive coronary artery disease (CAD) in the population under evaluation. Despite the high prevalence of CAD in patients treated with TAVR, the management strategy of concomitant CAD in these patients remains an area of considerable uncertainty.

RECENT FINDINGS

Percutaneous coronary intervention (PCI) in patients with CAD and severe AS has been shown to be feasible and safe. Whether revascularization before, during, or after TAVR is optimal remains a subject of debate. All three approaches represent valid strategies with advantages and disadvantages that need to be carefully weighed on an individual basis. Current expert opinions recommend that PCI should be performed before or at the time of TAVR as long as the risk of the procedure does not outweigh the potential benefits. The results of large clinical trials evaluating the optimal revascularization time are closely awaited.

Coronary Revascularisation in Transcatheter Aortic Valve Implantation Candidates: Why, Who, When?

Coronary artery disease (CAD) and aortic stenosis (AS) frequently coexist. The presence of CAD has been consistently associated with an impaired prognosis in patients undergoing surgical aortic valve replacement during short- and long-term follow-up. Accordingly, current guidelines recommend coronary revascularisation of all significant stenoses in patients undergoing surgical aortic valve replacement. Conversely, the management of concomitant CAD in patients with severe AS undergoing transcatheter aortic valve implantation (TAVI) is still a matter of debate. The aim of this review article is to provide an overview on the role of coronary revascularisation in TAVI patients.

The Value of the SYNTAX Score II in Predicting Clinical Outcomes in Patients Undergoing Transcatheter Aortic Valve Implantation

INTRODUCTION AND OBJECTIVES

The predictive value of the SYNTAX score (SS) for clinical outcomes after transcatheter aortic valve implantation (TAVI) is very limited and could potentially be improved by the combination of anatomic and clinical variables, the SS-II. We aimed to evaluate the value of the SS-II in predicting outcomes in patients undergoing TAVI.

METHODS

A total of 402 patients with severe symptomatic aortic stenosis undergoing transfemoral TAVI were included. Preprocedural TAVI angiograms were reviewed and the SS-I and SS-II were calculated using the SS algorithms. Patients were stratified in 3 groups according to SS-II tertiles. The coprimary endpoints were all-cause death and major adverse cardiovascular events (MACE), a composite of all-cause death, cerebrovascular event, or myocardial infarction at 1 year.

RESULTS

Increased SS-II was associated with higher 30-day mortality (P=.036) and major bleeding (P=.015). The 1-year risk of death and MACE was higher among patients in the 3rd SS-II tertile (HR, 2.60; P=.002 and HR, 2.66; P<.001) and was similar among patients in the 2nd tertile (HR, 1.27; P=.507 and HR, 1.05; P=.895) compared with patients in the 1st tertile. The highest SS-II tertile was an independent predictor of long-term mortality (P=.046) and MACE (P=.001).

CONCLUSIONS

The SS-II seems more suited to predict clinical outcomes in patients undergoing TAVI than the SS-I. Increased SS-II was associated with poorer clinical outcomes at 1 and 4 years post-TAVI, independently of the presence of coronary artery disease.

Impact of coronary artery disease in patients undergoing transfemoral transcatheter aortic valve implantation

BACKGROUND

The impact of coronary artery disease (CAD) and revascularization on outcome in patients undergoing transcatheter aortic valve implantation (TAVI) has not been fully elucidated so far.

OBJECTIVES

To assess whether the degree of CAD influences the prognosis of patients undergoing TAVI.

METHODS

Before TAVI, all patients underwent revascularization of the proximal vessels or the left main stem if indicated (stenosis ≥70% or 50%, respectively). In 666 patients, we calculated the baseline (bSS) and residual SYNTAX Score (rSS) prior to TAVI. In patients with revascularization, we determined the SYNTAX Revascularization Index (SRI=(1-(rSS/bSS))∗100). We also assessed the SYNTAX Score II (SS-II), combining anatomical and clinical variables. The primary endpoint was 3-year all-cause mortality.

RESULTS

Higher baseline and residual SYNTAX Score were associated with increased 3-year mortality (no CAD 26.2%, low bSS 34.8%, high bSS 46.8%; p=0.001, respectively, no CAD 25.9%, low rSS 31.4%, high rSS 41.5%; p=0.01). The extent of revascularization represented by the SRI was not associated with outcome. The SYNTAX Score II was also associated with increased 3-year mortality. However, baseline and residual SYNTAX Score as well as SYNTAX Score II did not independently predict mortality.

CONCLUSION

The anatomic severity of CAD as assessed by the baseline and residual SYNTAX Score is associated with survival after TAVI. Coronary artery disease seems to reflect general comorbidity burden and is associated with a higher risk profile of the patient.

Coronary Revascularization in Patients Undergoing Transcatheter Aortic Valve Replacement

Concomitant coronary artery disease (CAD) is highly prevalent among patients with severe aortic stenosis (AS). Historically, surgical aortic valve replacement with coronary artery bypass grafting was the only treatment option for patients with severe AS and significant CAD. The rapid expansion of transcatheter aortic valve replacement has led to significant paradigm shifts in the treatment of severe AS and has raised new questions regarding the optimal management of CAD in these patients. We review the evidence regarding management of concomitant CAD in severe AS patients, specifically focusing on issues surrounding transcatheter aortic valve replacement. In the absence of robust evidence supporting specific treatment strategies, decisions regarding coronary revascularization in severe AS should be individualized and made within the context of a multidisciplinary heart team.

Transcatheter Aortic Valve Implantation With or Without Percutaneous Coronary Artery Revascularization Strategy: A Systematic Review and Meta-Analysis

Background

Recent recommendations suggest that in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation and coexistent significant coronary artery disease, the latter should be treated before the index procedure; however, the evidence basis for such an approach remains limited. We performed a systematic review and meta‐analysis to study the clinical outcomes of patients with coronary artery disease who did or did not undergo revascularization prior to transcatheter aortic valve implantation.

Methods and Results

We conducted a search of Medline and Embase to identify studies evaluating patients who underwent transcatheter aortic valve implantation with or without percutaneous coronary intervention. Random‐effects meta‐analyses with the inverse variance method were used to estimate the rate and risk of adverse outcomes. Nine studies involving 3858 participants were included in the meta‐analysis. Patients who underwent revascularization with percutaneous coronary intervention had a higher rate of major vascular complications (odd ratio [OR]: 1.86; 95% confidence interval [CI], 1.33–2.60; P=0.0003) and higher 30‐day mortality (OR: 1.42; 95% CI, 1.08–1.87; P=0.01). There were no differences in effect estimates for 30‐day cardiovascular mortality (OR: 1.03; 95% CI, 0.35–2.99), myocardial infarction (OR: 0.86; 95% CI, 0.14–5.28), acute kidney injury (OR: 0.89; 95% CI, 0.42–1.88), stroke (OR: 1.07; 95% CI, 0.38–2.97), or 1‐year mortality (OR: 1.05; 95% CI, 0.71–1.56). The timing of percutaneous coronary intervention (same setting versus a priori) did not negatively influence outcomes.

Conclusions

Our analysis suggests that revascularization before transcatheter aortic valve implantation confers no clinical advantage with respect to several patient‐important clinical outcomes and may be associated with an increased risk of major vascular complications and 30‐day mortality. In the absence of definitive evidence, careful evaluation of patients on an individual basis is of paramount importance to identify patients who might benefit from elective revascularization.