Concomitant coronary intervention is associated with poorer early and late clinical outcomes in selected elderly patients receiving transcatheter aortic valve implantation

Staged Versus Concomitant TAVI and PCI for the Treatment of Coexisting Aortic Stenosis and Coronary Artery Disease

Aortic stenosis (AS) is one of the most common valvular pathologies. Severe coronary artery disease (CAD) often coexists with AS. Transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) have been established as alternatives to open surgical interventions. The data on the timing for the treatment of the 2 conditions are scarce and depend on multiple factors. This review compares the clinical outcomes of the concomitant versus staged PCI and TAVI for the treatment of AS and CAD. A systematic, electronic search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines to identify relevant articles that compared outcomes of the staged versus concomitant approaches for the TAVI and PCI. Seven studies were included involving 3745 patients. We found no statistically significant difference in primary outcomes such as 30-day mortality [odds ratio (OR) = 0.78; 95% confidence interval (CI): 0.39-1.57] and secondary outcomes including length of hospital stay (mean difference = -4.74, 95% CI: -10.96 to 1.48), new-onset renal failure (OR = 0.83, 95% CI: 0.22-3.13), cerebrovascular accidents (OR = 1.28, 95% CI: 0.64-2.57), and intraoperative blood loss (OR = 0.83, 95% CI: 0.32-2.12). New pacemaker insertion was statistically significant in favor of the concomitant approach (OR = 0.78, 95% CI: 0.63-0.96). This analysis suggests that while the 2 approaches are largely comparable in terms of most outcomes, patients at risk of requiring a pacemaker postprocedure may benefit from a concomitant approach. In conclusion, concomitant TAVI + PCI approach is nonsuperior to the staged approach for the treatment of CAD and AS. This review calls for robust trials in the field to further strengthen the evidence.

Comparison of the outcomes of concurrent versus staged TAVR combined with PCI in patients with severe aortic stenosis and coronary artery disease: a systematic review and meta-analysis

BACKGROUND

The optimal timing for percutaneous coronary intervention (PCI) in patients undergoing transcatheter aortic valve replacement (TAVR) remains uncertain. This research aims to evaluate the results of patients diagnosed with severe aortic valve stenosis and coronary artery disease who undergo either simultaneous or staged PCI therapy during TAVR procedures.

METHODS

We retrieved all relevant studies from our self-constructed databases up to January 2, 2024, encompassing databases such as Embase, Medline, Cochrane Library, and PubMed.

RESULTS

A total of nine studies were included, and the results showed that both surgical modalities had good safety profiles in the early and long-term stages. For early endpoint events, the risk of all-cause mortality and major bleeding within 30 years was similar in the staged TAVR + PCI and the contemporaneous TAVR + PCI (P > 0.05). Additionally, the risk of myocardial infarction, stroke, acute kidney injury and pacemaker implantation within 30 days or perioperatively is similar (P > 0.05). For long-term endpoint events, the risk of all-cause mortality, myocardial infarction and stroke was similar in the two groups at ≥2 years (P > 0.05).

CONCLUSION

In patients undergoing TAVR who required coronary revascularization, no significant differences were observed in the early and long-term outcomes between those receiving concurrent TAVR and PCI versus staged surgery.

Concomitant percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation

BACKGROUND

Patients undergoing transcatheter aortic valve implantation (TAVI) frequently have coronary artery disease requiring percutaneous coronary intervention (PCI). Usually, PCI and TAVI are performed in two separate procedures and current studies are investigating potential benefits regarding the order. However, the two interventions may also be performed simultaneously, thereby limiting the risk associated with repeated vascular access. Data evaluating benefit and harm of concomitant procedures are scarce.

AIMS

Therefore, this study aimed to evaluate concomitant PCI (coPCI) in TAVI patients regarding Valve Academic Research Consortium 3 (VARC-3) endpoints and long-term mortality.

METHODS

A total of 2233 consecutive TAVI patients from the EVERY-VALVE registry were analyzed according to the VARC-3 endpoint definitions. A total of 274 patients had undergone TAVI and concomitant PCI (coPCI group). They were compared to 226 TAVI patients who had received PCI within 60 days before TAVI in a stepwise approach (swPCI group) and to the remaining 1733 TAVI patients who had not undergone PCI recently (noPCI group).

RESULTS

Overall median age was 81.4 years, median Society of Thoracic Surgeons score was 4.0%. Patients in the coPCI and in the swPCI group were predominantly male with reduced left-ventricular ejection fraction. Rates of VARC-3 composite endpoints technical success and 30-day device success were comparable between all three groups. Mortality rates at 3 years after TAVI were similar (coPCI, 34.2% vs. swPCI, 31.9% vs. noPCI, 34.0% p = 0.84).

CONCLUSIONS

coPCI during TAVI seems comparable in a retrospective analysis. Compared to a stepwise approach, it has similar rates of composite endpoints technical success and device success as well as long-term mortality.

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.

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.

Multiple cardiac surgical procedures in a case of an octogenarian with essential thrombocythemia

BACKGROUND

Essential thrombocythemia (ET) is a chronic myeloproliferative disorder characterized by an elevation of platelet counts with a tendency for thrombosis and hemorrhage. The perioperative management of cardiovascular surgery of an ET patient is complicated. There is limited literature on the perioperative management of patients with ET undergoing cardiovascular surgery, particularly those requiring multiple procedures.

CASE PRESENTATION

An 85-year-old woman with a history of essential thrombocythemia (ET), which resulted in an abnormally high platelet count, was diagnosed with aortic valve stenosis, ischemic heart disease and paroxysmal atrial fibrillation. She underwent aortic valve replacement, coronary artery bypass grafting, and pulmonary vein isolation. The postoperative course was uneventful, nor hemorrhage and thrombosis.

CONCLUSIONS

We represent a case of perioperative management and successful treatment of three combined cardiac surgery for an octogenarian ET patient who is the oldest case ever reported.

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.

Staged versus concomitant transcatheter aortic valve replacement and percutaneous coronary intervention: A national analysis

Objective

Methods

Results

Conclusions

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.

A systematic review and meta-analysis of delayed coronary artery access for coronary angiography with or without percutaneous coronary intervention (PCI) in patients who underwent transcatheter aortic valve replacement (TAVR)

Coronary artery disease (CAD) and severe aortic valve stenosis frequently coexist. Given the progressive nature of CAD, silent or non-significant CAD may become symptomatic or functionally relevant years after TAVR. However, there is a paucity of data documenting the feasibility of either coronary angiography and/or PCI after TAVR. We systematically searched Medline, Pubmed, Embase, Cochrane database, Google Scholar, Science Direct, Web of Science, and conference abstracts from conception to March 2020 using OvidSP in TAVR patients undergoing coronary angiography with or without PCI at least 6 months after TAVR. Patients and procedural characteristics were summarized. The primary outcome of interest was successful coronary angiography for either the left main coronary artery (LMCA) or right coronary artery (RCA) with or without PCI. Pooled estimates were calculated using a random-effects meta-analysis. The study protocol was registered in PROSPERO. Eleven reports for a total of 696 coronary angiograms and 287 PCI were included in the analysis. Patients were slightly predominantly male, older and had a mean left ventricular ejection fraction of more than 50% with an intermediate STS. The summary estimate rates of successful LMCA and RCA angiography with a Medtronic self-expandable valve (SEV) were 84% (95% CI 73-90%, I² = 79, p = 0.015) and 69% (95% CI 37-89%, I² = 86, p = 0.23), respectively, while with the Edwards Lifesciences balloon expandable valve (BEV), the summary estimate rates for successful LMCA and RCA angiography were 94% (95% CI 72-99%, I² = 66, p = 0.003) and 95% (95% CI 48-99%, I² = 83, p = 0.05), respectively. The summary estimate rate of successful PCI post TAVR with either a Medtronic SEV or Edwards Lifesciences BEV was 93% (95% CI 86-96%, I² = 33, p = 0.0001). The overall achievement of a successful coronary angiography with or without PCI in post-TAVR patients is high, with a lower success rate for RCA angiography in patients with the Medtronic SEV Mortality and bleeding did not differ in our analysis.

Coronary Artery Disease and Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review

About one-half of transcatheter aortic valve replacement (TAVR) candidates have coronary artery disease (CAD), and controversial results have been reported regarding the effect of the presence and severity of CAD on clinical outcomes post-TAVR. In addition to coronary angiography, promising data has been recently reported on both the use of computed tomography angiography and the functional invasive assessment of coronary lesions in the work-up pre-TAVR. While waiting for the results of ongoing randomized trials, percutaneous revascularization of significant coronary lesions has been the routine strategy in TAVR candidates with CAD. Also, scarce data exists on the incidence, characteristics, and management of coronary events post-TAVR, and increasing interest exist on potential coronary access challenges in patients requiring coronary angiography/intervention post-TAVR. This review provides an updated overview of the current landscape of CAD in TAVR recipients, focusing on its prevalence, clinical impact, pre- and post-procedural evaluation and management, unresolved issues and future perspectives.

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.

[TAVI in women, very encouraging results]

The population of elderly patients comprises a high percentage of women. This population is more vulnerable due to the presence of numerous comorbidities and is, therefore, particularly exposed to the risk of aortic valve degeneration, resulting in aortic valve stenosis whose symptoms are predictors of poor short-term outcomes. In the presence of symptomatic aortic stenosis, the recommended therapeutic option in this vulnerable population is the implementation of transcatheter aortic valve implantation, preferably via the femoral route. The outcomes of this procedure are better in women than in men despite a more frequent occurrence of vascular, bleeding and cerebral complications. Several hypotheses have been reported in the literature regarding the reasons for such differences. Among other reasons, it is likely that in female patients, the myocardium adjusts better to the occurrence of aortic stenosis and that recovery after valve treatment is also more optimal. Another explanation is the higher frequency of coronary artery disease in this older population. This has a considerable impact on the outcome even when coronary lesions are treated prior to valve implantation. There is still room for improvement and progress can be achieved by further reducing the size of the equipment used in order to decrease the diameter of the vascular access, and by continuing to simplify TAVI procedures. Less invasive techniques should result in decreased complication rates. In addition, dedicated studies should allow us to further improve our practice in this growing population of vulnerable patients.

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."

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 safety of concomitant transcatheter aortic valve replacement and percutaneous coronary intervention: A systematic review and meta-analysis

BACKGROUND

TAVR is a rapidly spreading treatment option for severe aortic valve stenosis. Significant coronary artery disease (CAD) is present in 40% to 75% of patients undergoing TAVR. However, when to treat the concomitant coronary artery lesions is controversial.

METHODS

This is a systematic review comparing concomitant PCI and TAVR versus staged PCI and TAVR. The OVID database was systematically searched for studies reporting PCI in patients undergoing TAVR. A random effects model was used to calculate the pooled odds ratio (OR) with 95% confidence intervals.

RESULTS

Four observational studies and a total of 209 patients were included in this analysis. Overall 30-day mortality was similar between concomitant PCI and TAVR versus staged PCI and TAVR [OR: 1.47 (0.47-4.62); P = .51], renal failure was not significantly different between both groups [OR: 3.22 (0.61-17.12); P = .17], periprocedural myocardial infarction was not different between the 2 groups [OR: 1.44 (0.12-16.94); P = .77], life-threatening bleeding did not differ between both groups [OR: 0.45 (0.11-1.87); P = .27], and major stroke also was not significantly different [OR: 3.41 (0.16-74.2); P = .44].

CONCLUSION

These data did not show a significant difference in short-term outcomes between concomitant PCI and TAVR versus staged PCI and TAVR.

Transcatheter aortic valve implantation: where are we now?

Transcatheter aortic valve implantation (TAVI) was first used in clinical practice in 2002. Since 2002, there has been a rapid increase in TAVI activity in patients with symptomatic severe aortic stenosis. This has been supported by systematic randomized data comparing TAVI against the gold standard treatment for the last 50 years’ surgical aortic valve replacement. TAVI is now currently a recommended therapeutic intervention in the treatment of severe aortic stenosis patients who are deemed either high risk or inoperable. The indications for TAVI continue to expand. Within this review we will focus on the current guidelines for TAVI, the evidence for it, the complications of TAVI, postprocedure care, the technology available to clinicians now and finally the future perspectives for TAVI.

Optimized Screening of Coronary Artery Disease With Invasive Coronary Angiography and Ad Hoc Percutaneous Coronary Intervention During Transcatheter Aortic Valve Replacement

Background—

We sought to describe an optimized approach to coronary artery disease (CAD) screening and management in patients undergoing transcatheter aortic valve replacement (TAVR).

Methods and Results—

When invasive coronary angiography showed CAD, the treatment strategy and completeness of revascularization was determined based on coronary anatomy. TAVR was performed in the same setting if percutaneous coronary intervention (PCI) was uncomplicated; otherwise TAVR was postponed. A total of 604 patients undergoing CAD screening at the time of TAVR procedure were prospectively included in this study. Severe CAD was found in 136 patients (22.5%). Among patients with severe CAD, 53 patients (8.8%) underwent uncomplicated PCI. After PCI, TAVR was postponed in 2 patients (0.3%). In 83 patients (13.8%), coronary angiography showed severe CAD that was left untreated. After TAVR, all-cause and cardiovascular 30-day mortality rates were 2.4% and 1.4%, respectively. Disabling stroke, myocardial infarction, and life-threatening bleeding occurred in 0.5%, 0.8%, and 4.0% of patients, respectively. Acute kidney injury II or III rate was 3.3%. At 2 years, all-cause mortality rate was 14.1%. Disabling stroke and myocardial infarction occurred in 2.5% and 1.8% of patients, respectively. Patients undergoing TAVR and PCI in the same session had similar rate of the composite of death, disabling stroke, and myocardial infarction when compared with patients without CAD, and patients with severe CAD left untreated (TAVR+PCI: 10.4%; severe CAD left untreated: 15.4%; no-CAD: 14.8%; P =0.765).

Conclusions—

In patients undergoing TAVR, screening of CAD with invasive coronary angiography and ad hoc PCI during TAVR is feasible and was not associated with increased periprocedural risks. PCI followed by TAVR in the same session had similar outcomes than TAVR in which PCI was not performed.

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.

[Transfemoral TAVI procedure in women: Minimally-invasive technique]

Demographic data point to a substantial proportion of women in the population of elderly patients with an increasing prevalence of aortic stenosis. Implantation of an aortic bioprosthesis via an endovascular approach known as Transcatheter aortic valve implantation (TAVI) in patients presenting with a symptomatic tight aortic stenosis (severe aortic stenosis) (AS) is an alternative therapeutic option to surgical aortic valve replacement in patients at high surgical risk or ineligible for surgery. The literature has shown that this technique seems to be particularly beneficial in female patients. In the Partner A trial, the 1-year mortality rate was significantly lower in women compared to their male counterparts. Other data revealed that although women have a higher risk of experiencing periprocedural complications (vascular events, bleeding and stroke), their outcome is good and often better than that of men. These results are continuously improving thanks to the enhancement of techniques and devices. In view of the published reports reflecting the increasing experience of the teams, it clearly appears that the simplification of TAVI procedures has resulted in improved outcomes. We report here the case of a patient treated by means of a "minimalist" approach to TAVI allowing a reduction of the risks inherent in the procedure. This simplified strategy relies on an optimal use of CT scan findings prior to TAVI. The procedure is carried out under local anesthesia and the main access site is sutured percutaneously (Proglides). The radial artery is used as a secondary access site. Contrast medium is diluted and stimulation is administered via the intraventricular guidewire. Direct stenting is performed when deemed feasible on the basis of CT scan results. Simplified procedures such as these contribute to the improvement of TAVI outcomes. However, further studies focusing on female patients are warranted in order to corroborate these findings.

Functional Assessment of Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Implantation

Background—

Aortic valve stenosis may influence fractional flow reserve (FFR) of concomitant coronary artery disease by causing hypertrophy and reducing the vasodilatory reserve of the coronary circulation. We sought to investigate whether FFR values might change after valve replacement.

Methods and Results—

The functional relevance of 133 coronary lesions was assessed by FFR in 54 patients with severe aortic valve stenosis before and after transcatheter aortic valve implantation (TAVI) during the same procedure. A linear mixed model was used to verify the interaction of TAVI effect with the FFR values. No significant overall change in FFR values was found before and after the aortic valve stenosis removal (0.89±0.10 versus 0.89±0.13; P =0.73). A different trend in FFR groups (positive if ≤0.8; negative if >0.8) was found after TAVI ( P for interaction <0.001). Positive FFR values worsened after TAVI (0.71±0.11 versus 0.66±0.14). Conversely, negative FFR values improved after TAVI (0.92±0.06 versus 0.93±0.07). Similarly, FFR values in coronary arteries with lesions presenting percent diameter stenosis >50 worsened after TAVI (0.84±0.12 versus 0.82±0.16; P =0.02), whereas FFR values in arteries with mild lesions (percent diameter stenosis <50) tended toward improvement after TAVI (0.90±0.07 versus 0.91±0.09; P =0.69). Functional FFR variations after TAVI changed the indication to treat the coronary stenosis in 8 of 133 (6%) lesions.

Conclusions—

Coronary hemodynamics are influenced by aortic valve stenosis removal. Nevertheless, FFR variations after TAVI are minor and crossed the diagnostic cutoff of 0.8 in a small number of patients after valve replacement. Borderline coronary lesions might become functionally significant after valve replacement, although FFR-guided interventions were infrequent even in patients with angiographically significant lesions.

Reducing Patient Radiation Dose With Image Noise Reduction Technology in Transcatheter Aortic Valve Procedures

X-ray radiation exposure is of great concern for patients undergoing structural heart interventions. In addition, a larger group of medical staff is required and exposed to radiation compared with percutaneous coronary interventions. This study aimed at quantifying radiation dose reduction with implementation of specific image noise reduction technology (NRT) in transcatheter aortic valve implantation (TAVI) procedures. We retrospectively analyzed 104 consecutive patients with TAVI procedures, 52 patients before and 52 after optimization of x-ray radiation chain, and implementation of NRT. Patients with 1-step TAVI and complex coronary intervention, or complex TAVI procedures, were excluded. Before the procedure, all patients received a multislice computed tomography scan, which was used to size aortic annulus, select the optimal implantation plane, valve type and size, and guide valve implantation using a software tool. Air kerma and kerma-area product were compared in both groups to determine patient radiation dose reduction. Baseline parameters, co-morbidity, or procedural data were comparable between groups. Mean kerma-area product was significantly lower (p <0.001) in the NRT group compared with the standard group (60 ± 39 vs 203 ± 106 Gy × cm(2), p <0.001), which corresponds to a reduction of 70%. Mean air kerma was reduced by 64% (494 ± 360 vs 1,355 ± 657 mGy, p <0.001). In conclusion, using optimized x-ray chain combined with specific image noise reduction technology has the potential to significantly reduce by 2/3 radiation dose in standard TAVI procedures without worsening image quality or prolonging procedure time.

Optimizing clinical outcomes of transcatheter aortic valve implantation patients with comorbidities

Transcatheter aortic valve implantation (TAVI) has revolutionized the management of high-risk or inoperable patients presenting with symptomatic severe aortic stenosis (AS). There are several factors to consider to optimize patient outcomes from TAVI. Before TAVI, patient selection is key and an understanding the effects of common comorbidities on outcomes after TAVI is critical. Some comorbidities share common risk factors with AS (e.g. coronary artery disease), others are directly or indirectly caused or exacerbated by severe AS (e.g. atrial fibrillation, pulmonary hypertension, mitral regurgitation, tricuspid regurgitation and right ventricular dysfunction), whereas others are not directly related to severe AS (e.g. chronic kidney disease and chronic lung disease). Choice of transcatheter heart valve prosthesis, vascular access route and mode of anesthesia are important considerations during TAVI. New onset conduction disturbances and arrhythmias remain a vexing issue after TAVI. The aim of the present review is to provide an overview of these issues.

Coronary artery disease in patients undergoing TAVI--why not to treat

The management of coronary artery disease in the context of severe aortic stenosis in patients at increased surgical risk is an increasingly relevant problem in the transcatheter aortic valve implantation (TAVI) era. We review the current data on percutaneous coronary intervention (PCI) in TAVI patients and discuss how it has impacted upon our decision making, advocating that pre-TAVI revascularisation is not necessarily required.

Timing of staged percutaneous coronary intervention before transcatheter aortic valve implantation

Significant coronary artery disease is highly prevalent in patients who underwent transcatheter aortic valve implantation (TAVI). Timing of staged percutaneous coronary intervention (PCI) in TAVI candidates remains debated. The present study assessed the impact of timing of the staged PCI on TAVI outcomes. Ninety-six patients (age 81 ± 5 years, 57% men) who had undergone staged PCI within 1 year before TAVI were included. The population was dichotomized according to the median time elapsed between PCI and TAVI (<30 and ≥30 days). In-hospital events and 30-day outcomes after TAVI were defined according to Valve Academic Research Consortium-2 definitions. Forty-eight patients underwent PCI <30 days and 48 patients underwent PCI ≥30 days before TAVI. Patients treated with PCI <30 days had lower hemoglobin levels at baseline (7.2 ± 0.9 mmol/L vs 7.9 ± 0.9 mmol/L, p = 0.002), more frequently atrial fibrillation (27% vs 13%, p = 0.018), and a shorter time interval between computed tomography acquisition and TAVI (7 days [2 to 10] vs 22 days [6 to 39], p <0.001) than their counterparts. Minor bleedings (13% vs 0%, p = 0.011) and overall vascular injury (27% vs 8%, p = 0.016 [minor injury: 17% vs 2%, p = 0.014; major injury: 10% vs 6%, p = 0.460]) were more frequently recorded in patients with staged PCI <30 days before TAVI. There were no differences in the incidence of other events and in 2-year survival. In conclusion, shortly (<30 days) or remote (≥30 days) staged PCI before TAVI resulted in comparable outcomes with the exception of minor vascular injury and minor bleeding events which were more frequently observed in patients treated with shortly staged PCI.

Indications for transcatheter aortic valve implantation--now and next?

Aortic stenosis (AS) is the most common valvular pathology and its prevalence is expected to increase rapidly in coming decades as a consequence of the increasingly elderly population. Without treatment, severe symptomatic AS has a very poor prognosis with a mortality of 50% at two years. Whilst surgical aortic valve replacement is the gold standard treatment, a significant minority of patients are deemed inoperable and declined surgery due to prohibitively high risk. The advent of transcatheter aortic valve implantation (TAVI) has revolutionised their treatment. In this review, we discuss current indications for TAVI, other applications of this technology and future indications.

Challenges of coronary angiography and intervention in patients previously treated by TAVI

OBJECTIVE

Since the beginning of the transcatheter aortic valve implantation (TAVI) era, many prosthetic valves have entered clinical practice. TAVI prostheses differ regarding stent design and some may potentially interfere with diagnostic or interventional catheters. The aim of our analysis was to evaluate the feasibility of coronary angiography (CA) or percutaneous coronary intervention (PCI) in patients with prior TAVI.

METHODS

From 2011 to 2014, 1,000 patients were treated by TAVI at our center using eight different valve prostheses (Symetis ACURATE TA and ACURATE TF; Medtronic CoreValve and Engager; JenaValve, SJM Portico; Edwards Lifesciences SAPIEN and SAPIEN XT). In this analysis, all patients were included who underwent either CA or PCI after TAVI. CA or PCI were rated as fully feasible when coronary ostia could be fully intubated, partially feasible when coronary arteries could be displayed only unselectively or unfeasible when coronary arteries could not be displayed.

RESULTS

A total of 35 patients underwent CA/PCI after TAVI at our hospital. In all patients with valves implanted in a subcoronary position (SAPIEN n = 19; JenaValve n = 1), selective intubation was feasible using standard catheters. Out of 15 patients with valve types that are placed over the coronary ostia (CoreValve n = 10, ACURATE n = 4, Portico n = 1), selective intubation of coronary arteries was not possible in 9 cases, even with the use of different diagnostic catheters. Full accessibility was possible only in 3 cases. In 2 cases, display of the right CA was only feasible using unselective aortography. In 1 case, coronary arteries could not be displayed at all immediately after a valve-in-valve procedure.

CONCLUSION

CA or PCI after TAVI is usually feasible. Devices that are placed in a partially supracoronary position, however, can interfere with diagnostic or guiding catheters and impede straightforward intervention, especially when the prosthesis is not implanted in the correct position.

Management of Coronary Disease in the Era of Transcatheter Aortic Valve Replacement: Comprehensive Review of the Literature

Among the cohort of complex and multifaceted patients undergoing transcatheter aortic valve replacement (TAVR), the prevalence of coronary artery disease (CAD) ranges from 48% to 75%. However, optimal management of CAD in this setting has not been established. This article provides a comprehensive review of the literature to depict the actual knowledge on the subject of aortic stenosis and concomitant CAD. This article also aids heart teams in their decision-making process to appropriately manage these challenging patients with aortic stenosis and CAD. Upcoming randomized studies will clarify the influence of CAD, the best timing for percutaneous coronary intervention, and its impact on TAVR results.

Concomitant coronary intervention is associated with poorer early and late clinical outcomes in selected elderly patients receiving transcatheter aortic valve implantation

OBJECTIVES

Significant coronary artery disease (CAD) is common among patients currently evaluated for transcatheter aortic valve implantation (TAVI). Limited data exist on the outcome of patients undergoing combined transcatheter treatment of aortic valve disease and CAD. The aim of the study was to analyse the impact of concomitant percutaneous coronary intervention (PCI) on early and late clinical outcomes of patients receiving TAVI.

METHODS

TAVIs were performed through either transfemoral or transapical access using SAPIEN (XT), CoreValve or AcurateTA valves. PCI was decided by the interdisciplinary heart team and performed synchronously or as a staged procedure upfront. Standardized valve academic research consortium (VARC)-2 endpoints were used. In case of a staged approach, TAVI was defined as the index procedure. Thirty-day outcomes and Kaplan-Meier 2-year survival were analysed.

RESULTS

Of 411 TAVIs, 65 (16%) received PCI. Mean age was 82 years (P = 0.92) and mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 21.7% (TAVI + PCI) and 20.3% (TAVI; P = 0.47). PCI was performed as staged procedure upfront (74%) or synchronously (26%). In 95% of PCIs, a single coronary artery was treated, and 71% received bare metal stents. Incidence of myocardial infarction (6 vs 1%; P = 0.01) and 30-day mortality (15 vs 5%; P = 0.01) were higher in the TAVI + PCI group, compared with the TAVI group. Synchronous (18%) vs staged (15%) approach for PCI had comparable early mortality (P = 1.0). Kaplan-Meier 2-year survival was poorer in the TAVI + PCI group (P = 0.03) with an odds ratio of 1.66 (P = 0.04).

CONCLUSIONS

Concomitant PCI is--when based on current heart team practice--associated with increased early and late mortality in selected elderly patients undergoing TAVI.