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Jo HH, Kang DY, Lee JM, Lim SM, Park YS, Choi Y, Kim H, Lee J, Ahn JM, Park DW, Park SJ. Evaluation of Instantaneous Wave-Free Ratio and Fractional Flow Reserve in Severe Aortic Valve Stenosis. Circ Cardiovasc Interv 2024; 17:e013237. [PMID: 38629298 DOI: 10.1161/circinterventions.123.013237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 02/08/2024] [Indexed: 04/30/2024]
Abstract
BACKGROUND The optimal functional evaluation of coronary artery stenosis in patients with severe aortic stenosis (AS) has not been established. The objective of the study was to evaluate the instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) in patients with and without severe AS. METHODS We retrospectively investigated 395 lesions in 293 patients with severe AS and 2257 lesions in 1882 patients without severe AS between 2010 and 2022 from a subgroup of the Interventional Cardiology Research In-Cooperation Society FFR Registry. All patients had FFR values, and iFR was analyzed post hoc using dedicated software only in lesions with adequate resting pressure curves (311 lesions in patients with severe AS and 2257 lesions in patients with nonsevere AS). RESULTS The incidence of iFR ≤0.89 was 66.6% and 31.8% (P<0.001), while the incidence of FFR ≤0.80 was 45.3% and 43.9% (P=0.60) in the severe AS group and the nonsevere AS group, respectively. In the severe AS group, most lesions (95.2%) with iFR >0.89 had FFR >0.80, while 36.2% of lesions with iFR ≤0.89 had FFR >0.80. During a median follow-up of 2 years, FFR ≤0.80 was significantly associated with deferred lesion failure (adjusted hazard ratio, 2.71 [95% CI, 1.08-6.80]; P=0.034), while iFR ≤0.89 showed no prognostic value (adjusted hazard ratio, 1.31 [95% CI, 0.47-3.60]; P=0.60) in the severe AS group. Lesions with iFR ≤0.89 and FFR >0.80, in particular, were not associated with a higher rate of deferred lesion failure at 3 years compared with lesions with iFR >0.89 (15.4% versus 17.0%; P=0.58). CONCLUSIONS This study suggested that FFR appears to be less affected by the presence of severe AS and is more associated with prognosis. iFR may overestimate the functional severity of coronary artery disease without prognostic significance, yet it can be useful for excluding significant stenosis in patients with severe AS.
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Affiliation(s)
- Ha Hye Jo
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Do-Yoon Kang
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joong Min Lee
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - So-Min Lim
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young-Sun Park
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yeonwoo Choi
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hoyun Kim
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jinho Lee
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jung-Min Ahn
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Duk-Woo Park
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seung-Jung Park
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Ribichini F, Pesarini G, Fabris T, Lunardi M, Barbierato M, D'Amico G, Zanchettin C, Gregori D, Piva T, Nicolini E, Gandolfo C, Fineschi M, Petronio AS, Berti S, Caprioglio F, Saia F, Sclafani R, Esposito G, D'Ascenzo F, Tarantini G. A randomised multicentre study of angiography- versus physiologyguided percutaneous coronary intervention in patients with coronary artery disease undergoing TAVI: design and rationale of the FAITAVI trial. EUROINTERVENTION 2024; 20:e504-e510. [PMID: 38629420 PMCID: PMC11017223 DOI: 10.4244/eij-d-23-00679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/16/2024] [Indexed: 04/19/2024]
Abstract
The treatment of coronary artery disease (CAD) in patients with severe aortic valve stenosis (AVS) eligible for transcatheter aortic valve implantation (TAVI) is not supported by clinical evidence, and the role of physiology over anatomy as well as the timing of coronary intervention are not defined. FAITAVI (ClinicalTrials.gov: NCT03360591) is a nationwide prospective, open-label, multicentre, randomised controlled study comparing the angiography-guided versus the physiology-guided coronary revascularisation strategy in patients with combined significant CAD and severe AVS undergoing TAVI. Significant CAD will be defined as coronary stenosis ≥50%, as assessed by visual estimation in vessels ≥2.5 mm. Physiology will be tested by fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR). The study will be conducted at 15 sites in Italy. In the angiography arm, percutaneous coronary intervention (PCI) will be performed either before TAVI, during the TAVI procedure - before or after the valve implantation - or within 1 month±5 days of the valve implantation, left to the operator's decision. In the physiology arm, FFR and iFR will be performed before TAVI, and PCI will be indicated for FFR ≤0.80, otherwise the intervention will be deferred. In case of borderline values (0.81-0.85), FFR and iFR will be repeated after TAVI, with PCI performed when needed. With a sample size of 320 patients, the study is powered to evaluate the primary endpoint (a composite of death, myocardial infarction, stroke, major bleeding, or ischaemia-driven target vessel revascularisation). TAVI indication, strategy and medical treatment will be the same in both groups. After discharge, patients will be contacted at 1, 6, 12 and 24 months after the procedure to assess their general clinical status, and at 12 months for the occurrence of events included in the primary and secondary endpoints. FAITAVI is the first randomised clinical trial to investigate "optimal" percutaneous coronary intervention associated with TAVI in patients with severe AVS and CAD.
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Affiliation(s)
- Flavio Ribichini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Gabriele Pesarini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Tommaso Fabris
- Department of Cardiac, Thoracic and Vascular Science, University of Padova, Padova, Italy
| | - Mattia Lunardi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Marco Barbierato
- Division of Cardiology, Ospedale dell'Angelo di Mestre, Chirignago-Zelarino, Italy
| | - Gianpiero D'Amico
- Division of Cardiology, Ospedale dell'Angelo di Mestre, Chirignago-Zelarino, Italy
| | - Chiara Zanchettin
- Department of Cardiac, Thoracic and Vascular Science, University of Padova, Padova, Italy
- Division of Cardiology, Ospedale dell'Angelo di Mestre, Chirignago-Zelarino, Italy
| | - Dario Gregori
- Department of Cardiac, Thoracic and Vascular Science, University of Padova, Padova, Italy
| | - Tommaso Piva
- Division of Cardiology, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Elisa Nicolini
- Division of Cardiology, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | | | - Massimo Fineschi
- Division of Cardiology, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Anna Sonia Petronio
- Division of Cardiology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Sergio Berti
- Division of Cardiology, Ospedale del Cuore - Fondazione Monasterio, Massa, Italy
| | | | - Francesco Saia
- Division of Cardiology, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Rocco Sclafani
- Division of Cardiology, Azienda Ospedaliera di Perugia - Ospedale S. Maria della Misericordia, Perugia, Italy
| | - Giovanni Esposito
- Division of Cardiology, Policlinico Universitario Federico II di Napoli, Napoli, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, Hospital University of Turin, Torino, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Science, University of Padova, Padova, Italy
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3
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Kedhi E, Rroku A, Hermanides RS, Dambrink JH, Singh S, Berg JT, van Ginkel DJ, Hudec M, Amoroso G, Amat-Santos IJ, Andreas M, Teles RC, Bonnet G, Van Belle E, Conradi L, van Garsse L, Wojakowski W, Voudris V, Sacha J, Cervinka P, Lipsic E, Somi S, Nombela-Franco L, Postma S, Piayda K, De Luca G, Malinofski K, Modine T. TransCatheter aortic valve implantation and fractional flow reserve-guided percutaneous coronary intervention versus conventional surgical aortic valve replacement and coronary bypass grafting for treatment of patients with aortic valve stenosis and multivessel or advanced coronary disease: The transcatheter valve and vessels trial (TCW trial): Design and rationale. Am Heart J 2024; 270:86-94. [PMID: 38309610 DOI: 10.1016/j.ahj.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND Patients with severe aortic stenosis (AS) frequently present with concomitant obstructive coronary artery disease (CAD). In those, current guidelines recommend combined coronary artery bypass grafting (CABG) and surgical aortic valve replacement (SAVR) as the preferred treatment option, although this surgical approach is associated with a high rate of clinical events. Combined transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) with or without FFR have evolved as a valid alternative for cardiac surgery in patients with AS and multivessel or advanced CAD. To date, no dedicated trial has prospectively evaluated the outcomes of a percutaneous versus surgical treatment for patients with both severe AS and CAD. AIMS To investigate whether fractional-flow reserve (FFR)-guided PCI and TAVI is noninferior to combined CABG and SAVR for the treatment of severe AS and multivessel or advanced CAD. METHODS The Transcatheter Valve and Vessels (TCW) trial (clinicaltrial.gov: NCT03424941) is a prospective, randomized, controlled, open label, international trial. Patients ≥ 70 years with severe AS and multivessel (≥ 2 vessels) or advanced CAD, deemed feasible by the heart team for both; a full percutaneous or surgical treatment, will be randomised in a 1:1 fashion to either FFR-guided PCI followed by TAVI (intervention arm) vs. CABG and SAVR (control arm). The primary endpoint is a patient-oriented composite of all-cause mortality, myocardial infarction, disabling stroke, unscheduled clinically-driven target vessel revascularization, valve reintervention, and life threatening or disabling bleeding at 1 year. The TCW trial is powered for noninferiority, and if met, superiority will be tested. Assuming a primary endpoint rate of 30% in the CABG-SAVR arm, with a significance level α of 5%, a noninferiority limit delta of 15% and a loss to follow-up of 2%, a total of 328 patients are needed to obtain a power of 90%. The primary endpoint analysis is performed on an intention-to-treat basis. SUMMARY The TCW Trial is the first prospective randomized trial that will study if a less invasive percutaneous treatment for severe AS and concomitant advanced CAD (i.e., FFR-guided PCI-TAVI) is noninferior to the guidelines recommended approach (CABG-SAVR).
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Affiliation(s)
- Elvin Kedhi
- McGill University Health Center, Montreal, Quebec, Canada; Department of Cardiology and Structural Heart Disease, Medical University of Silesia, Katowice, Poland.
| | - Andi Rroku
- Department of Cardiology, Deutsches Herzzentrum der Charité, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Rik S Hermanides
- Isala Heart Center, Department of Cardiology, Zwolle, The Netherlands
| | - Jan Henk Dambrink
- Isala Heart Center, Department of Cardiology, Zwolle, The Netherlands
| | - Sandeep Singh
- Isala Heart Center, Department of Thoracic Surgery, Zwolle, The Netherlands
| | - Jurriën Ten Berg
- St.Antonius Ziekenhuis, Nieuwegein, The Netherlands and University Medical Center Maastricht, Maastricht, The Netherlands
| | - Dirk-Jan van Ginkel
- St.Antonius Ziekenhuis, Nieuwegein, The Netherlands and University Medical Center Maastricht, Maastricht, The Netherlands
| | | | - Giovanni Amoroso
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Ignacio J Amat-Santos
- Centro de Investigación Biomdica en Red, Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Rui Campante Teles
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Guillaume Bonnet
- Medico-Surgical Department (Valvulopathies, Cardiac Surgery, Adult Interventional Cardiology), Hôpital Cardiologique de Haut-Lévèque, Bordeaux University Hospital, France
| | - Eric Van Belle
- CHU Lille, Department of Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Institut Coeur Puomon, Inserm, U1011, Institut Pasteur de Lille, EGIG, Université de Lille, Lille, France
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Germany
| | - Leen van Garsse
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, The Netherlands
| | - Wojtek Wojakowski
- Department of Cardiology and Structural Heart Disease, Medical Univ. Silesia, Katowice, Poland
| | - Vasileious Voudris
- Interventional Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Jerzy Sacha
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland; Faculty of Physical Education and Physiotherapy, Opole University of Technology, Opole, Poland
| | - Pavel Cervinka
- Department of Cardiology, Krajska Zdravotni A.S., Masaryk Hospital and UJEP Usti nad Labem, Czech Republic
| | - Erik Lipsic
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Samer Somi
- Department of Cardiology, Haga Hospital, The Hague, The Netherlands
| | | | | | - Kerstin Piayda
- Department of Cardiology and Vascular Medicine, Medical Faculty, Justus-Liebig-University Giessen, Giessen, Germany
| | - Giuseppe De Luca
- Division of Clinical and Experimental Cardiology, AOU Sassari, University of Sassari, Sassari, Italy
| | - Krzysztof Malinofski
- Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Kraków, Poland; Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Thomas Modine
- Medico-Surgical Department (Valvulopathies, Cardiac Surgery, Adult Interventional Cardiology), Hôpital Cardiologique de Haut-Lévèque, Bordeaux University Hospital, France
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4
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Paolisso P, Gallinoro E, Vanderheyden M, Esposito G, Bertolone DT, Belmonte M, Mileva N, Bermpeis K, De Colle C, Fabbricatore D, Candreva A, Munhoz D, Degrieck I, Casselman F, Penicka M, Collet C, Sonck J, Mangiacapra F, de Bruyne B, Barbato E. Absolute coronary flow and microvascular resistance reserve in patients with severe aortic stenosis. HEART (BRITISH CARDIAC SOCIETY) 2022; 109:47-54. [PMID: 35977812 DOI: 10.1136/heartjnl-2022-321348] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Development of left ventricle (LV) hypertrophy in aortic stenosis (AS) is accompanied by adaptive coronary flow regulation. We aimed to assess absolute coronary flow, microvascular resistance, coronary flow reverse (CFR) and microvascular resistance reserve (MRR) in patients with and without AS. METHODS Absolute coronary flow and microvascular resistance were measured by continuous thermodilution in 29 patients with AS and 29 controls, without AS, matched for age, gender, diabetes and functional severity of epicardial coronary lesions. Myocardial work, total myocardial mass and left anterior descending artery (LAD)-specific mass were quantified by echocardiography and cardiac-CT. RESULTS Patients with AS presented a significantly positive LV remodelling with lower global longitudinal strain and global work efficacy compared with controls. Total LV myocardial mass and LAD-specific myocardial mass were significantly higher in patients with AS (p=0.001). Compared with matched controls, absolute resting flow in the LAD was significantly higher in the AS cohort (p=0.009), resulting into lower CFR and MRR in the AS cohort compared with controls (p<0.005 for both). No differences were found in hyperaemic flow and resting and hyperaemic resistances. Hyperaemic myocardial perfusion (calculated as the ratio between the absolute coronary flow subtended to the LAD, expressed in mL/min/g), but not resting, was significantly lower in the AS group (p=0.035). CONCLUSIONS In patients with severe AS and non-obstructive coronary artery disease, with the progression of LV hypertrophy, the compensatory mechanism of increased resting flow maintains adequate perfusion at rest, but not during hyperaemia. As a consequence, both CFR and MRR are significantly impaired.
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Affiliation(s)
- Pasquale Paolisso
- Hartcentrum OLV Aalst, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | | | | | - Giuseppe Esposito
- Hartcentrum OLV Aalst, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | - Dario Tino Bertolone
- Hartcentrum OLV Aalst, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | - Marta Belmonte
- Hartcentrum OLV Aalst, Aalst, Belgium.,Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Lombardia, Italy
| | | | | | - Cristina De Colle
- Hartcentrum OLV Aalst, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | - Davide Fabbricatore
- Hartcentrum OLV Aalst, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | | | - Daniel Munhoz
- Hartcentrum OLV Aalst, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | - Ivan Degrieck
- Cardiovascular and Thoracic Surgery, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Filip Casselman
- Cardiovascular and Thoracic Surgery, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Martin Penicka
- Cardiology, Hartcentrum OLV Aalst, Aalst, Flanderen, Belgium
| | | | | | | | | | - Emanuele Barbato
- Hartcentrum OLV Aalst, Aalst, Belgium .,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
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5
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The stability of flow velocity and intracoronary resistance in the intracoronary electrocardiogram-triggered pressure ratio. Sci Rep 2021; 11:13824. [PMID: 34226618 PMCID: PMC8257648 DOI: 10.1038/s41598-021-93181-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/22/2021] [Indexed: 01/10/2023] Open
Abstract
Assessment of coronary artery lesions using the fractional flow reserve and instantaneous flow reserve (iFR) measurements has been found to reduce the incidence of further cardiovascular events. Here, we investigated differences in terms of coronary flow velocity and resistance within the analysis interval between the iFR and the intracoronary electrocardiogram (IC-ECG)-triggered distal/aortic pressure (Pd/Pa) ratio (ICE-T). We enrolled 23 consecutive patients (n = 33 stenoses) who required coronary flow measurements. ICE-T was defined as the average Pd/Pa ratio in the period corresponding to the isoelectric line of the IC-ECG. We compared the index value, flow velocity, and intracoronary resistance during the analysis intervals of the iFR and the ICE-T, both at rest and under hyperemia. ICE-T values and ICE-T intracoronary resistance were both found to be significantly lower, whereas flow velocity was significantly higher than those of the iFR at both rest and under hyperemia (P < 0.001), and all fluctuations in ICE-T values were also significantly smaller than those in the iFR. In conclusion, the ICE-T appears theoretically superior to pressure-dependent indices for analyzing phases with low and stable resistance, without an increase in invasiveness.
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Pathophysiology, Diagnosis, and Treatment of Patients with Concomitant Severe Aortic Stenosis and Coronary Artery Disease: A Closer Look to the Unresolved Perplexity. J Clin Med 2021; 10:jcm10081617. [PMID: 33920349 PMCID: PMC8070187 DOI: 10.3390/jcm10081617] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/01/2021] [Accepted: 04/08/2021] [Indexed: 01/09/2023] Open
Abstract
Degenerative aortic stenosis (AS) and coronary artery disease (CAD) are the most prevalent cardiovascular diseases in developed countries, and they coexist in up to 50% of patients. The pathophysiological rationale behind concomitant AS and CAD is discussed in detail in this review, together with prognostic implications. Detecting CAD in patients with AS may be challenging, as AS may mask the existence and symptoms of CAD. The safety and reliability of invasive and non-invasive physiological assessment for epicardial coronary disease are also a matter of debate. Finally, the selection and timing of optimal treatment of CAD in patients with severe AS are still unclear. Given the aging of the population, the increase in the prevalence of AS, and the ongoing paradigm shift in its treatment, controversies in the diagnosis and treatment of CAD in the setting of AS are deemed to grow in importance. In this paper, we present contemporary issues in the diagnosis and management of CAD in patients with severe AS who are transcatheter aortic valve implantation (TAVI) candidates and provide perspective on the treatment approach.
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7
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Marin F, Scarsini R, Kotronias RA, Printzios DT, Burrage MK, Bray JJH, Ciofani JL, Venturi G, Pighi M, De Maria GL, Banning AP. Aortic Valve Disease and Associated Complex CAD: The Interventional Approach. J Clin Med 2021; 10:946. [PMID: 33804391 PMCID: PMC7957505 DOI: 10.3390/jcm10050946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/19/2021] [Accepted: 02/20/2021] [Indexed: 01/09/2023] Open
Abstract
Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis (AS). The management of CAD is a central aspect of the work-up of patients undergoing transcatheter aortic valve implantation (TAVI), but few data are available on this field and the best percutaneous coronary intervention (PCI) practice is yet to be determined. A major challenge is the ability to elucidate the severity of bystander coronary stenosis independently of the severity of aortic valve stenosis and subsequent impact on blood flow. The prognostic role of CAD in patients undergoing TAVI is being still debated and the benefits and the best timing of PCI in this context are currently under evaluation. Additionally, PCI in the setting of advanced AS poses some technical challenges, due to the complex anatomy, risk of hemodynamic instability, and the increased risk of bleeding complications. This review aims to provide a comprehensive synthesis of the available literature on myocardial revascularization in patients with severe AS undergoing TAVI. This work can assist the Heart Team in individualizing decisions about myocardial revascularization, taking into account available diagnostic tools as well as the risks and benefits.
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Affiliation(s)
- Federico Marin
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford OX3 9DU, UK; (F.M.); (R.A.K.); (D.T.P.); (M.K.B.); (G.L.D.M.)
| | - Roberto Scarsini
- Department of Cardiology, University of Verona, 37129 Verona, Italy; (R.S.); (G.V.); (M.P.)
| | - Rafail A. Kotronias
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford OX3 9DU, UK; (F.M.); (R.A.K.); (D.T.P.); (M.K.B.); (G.L.D.M.)
| | - Dimitrios Terentes Printzios
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford OX3 9DU, UK; (F.M.); (R.A.K.); (D.T.P.); (M.K.B.); (G.L.D.M.)
| | - Matthew K. Burrage
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford OX3 9DU, UK; (F.M.); (R.A.K.); (D.T.P.); (M.K.B.); (G.L.D.M.)
| | - Jonathan J. H. Bray
- Institute of Life Sciences 2, Swansea Bay University Health Board and Swansea University Medical School, SA2 8QA Swansea, UK;
| | - Jonathan L. Ciofani
- Department of Cardiology, Royal North Shore Hospital, 2065 Sydney, Australia;
| | - Gabriele Venturi
- Department of Cardiology, University of Verona, 37129 Verona, Italy; (R.S.); (G.V.); (M.P.)
| | - Michele Pighi
- Department of Cardiology, University of Verona, 37129 Verona, Italy; (R.S.); (G.V.); (M.P.)
| | - Giovanni L. De Maria
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford OX3 9DU, UK; (F.M.); (R.A.K.); (D.T.P.); (M.K.B.); (G.L.D.M.)
| | - Adrian P. Banning
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford OX3 9DU, UK; (F.M.); (R.A.K.); (D.T.P.); (M.K.B.); (G.L.D.M.)
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8
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Scarsini R, Lunardi M, Venturi G, Pighi M, Tavella D, Pesarini G, Ribichini F. Long-term variations of FFR and iFR after transcatheter aortic valve implantation. Int J Cardiol 2020; 317:37-41. [PMID: 32504719 DOI: 10.1016/j.ijcard.2020.05.085] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/29/2020] [Accepted: 05/27/2020] [Indexed: 01/09/2023]
Abstract
Long-term variations of fractional flow reserve (FFR) and instantaneous wave-free-ratio (iFR) after transcatheter aortic valve implantation (TAVI) have not been previously assessed. A total of 23 coronary lesions in 14 patients with aortic stenosis (AS) underwent physiology assessment at baseline, immediately after TAVI and at 14(7-29) months of follow-up. The angiographic severity of the lesions did not progress at follow-up (54[45-64] vs 54[49-63], p = .53). Overall, FFR (0.87[0.85-0.92] vs 0.88[0.82-0.92], p = .45) and iFR (0.88[0.85-0.96] vs 0.91[0.86-0.97], p = .30) did not change significantly compared with the baseline. FFR decreased in 3(13%) lesions with abnormal baseline value, whereas it remained stable in lesions with FFR > 0.80. Conversely, iFR did not show a systematic trend at long-term after TAVI. However, iFR demonstrated a higher reclassification rate at follow-up compared with FFR (p = .02). In conclusions, in this exploratory study, only minor variations of coronary physiology indices were observed at long-term after TAVI. Nevertheless, caution should be exercised in the interpretation of borderline FFR and iFR values in severe AS.
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Affiliation(s)
- Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Italy
| | - Mattia Lunardi
- Division of Cardiology, Department of Medicine, University of Verona, Italy
| | - Gabriele Venturi
- Division of Cardiology, Department of Medicine, University of Verona, Italy
| | - Michele Pighi
- Division of Cardiology, Department of Medicine, University of Verona, Italy
| | - Domenico Tavella
- Division of Cardiology, Department of Medicine, University of Verona, Italy
| | - Gabriele Pesarini
- Division of Cardiology, Department of Medicine, University of Verona, Italy
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Italy.
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Lunardi M, Scarsini R, Venturi G, Pesarini G, Pighi M, Gratta A, Gottin L, Barbierato M, Caprioglio F, Piccoli A, Ferrero V, Ribichini F. Physiological Versus Angiographic Guidance for Myocardial Revascularization in Patients Undergoing Transcatheter Aortic Valve Implantation. J Am Heart Assoc 2019; 8:e012618. [PMID: 31718439 PMCID: PMC6915256 DOI: 10.1161/jaha.119.012618] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/19/2019] [Indexed: 12/23/2022]
Abstract
Background Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation is uncertain. Fractional flow reserve (FFR) has never been clinically validated in aortic stenosis. The study aim was to analyze the clinical outcome of FFR-guided revascularization in patients undergoing transcatheter aortic valve implantation. Methods and Results Patients with severe aortic stenosis and coronary artery disease at coronary angiography were included in this retrospective analysis and divided in 2 groups: angiography guided (122/216; 56.5%) versus FFR-guided revascularization (94/216; 43.5%). Patients were clinically followed up and evaluated for the occurrence of major adverse cardiac and cerebrovascular events at 2-year follow-up. Most lesions in the FFR group resulted negative according to the conventional 0.80 cutoff value (111/142; 78.2%) and were deferred. The FFR-guided group showed a better major adverse cardiac and cerebrovascular event-free survival compared with the angio-guided group (92.6% versus 82.0%; hazard ratio, 0.4; 95% CI, 0.2-1.0; P=0.035). Patients with deferred lesions based on FFR presented better outcome compared with patients who underwent angio-guided percutaneous coronary intervention (91.4% versus 68.1%; hazard ratio, 0.3; 95% CI, 0.1-0.6; P=0.001). Conclusions FFR guidance was associated with favorable outcome in this observational study in patients undergoing transcatheter aortic valve implantation. Randomized trials are needed to investigate the long-term effects of FFR-guided revascularization against angiographic guidance alone in patients with aortic stenosis.
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Affiliation(s)
- Mattia Lunardi
- Division of CardiologyDepartment of MedicineUniversity of VeronaItaly
| | - Roberto Scarsini
- Division of CardiologyDepartment of MedicineUniversity of VeronaItaly
| | - Gabriele Venturi
- Division of CardiologyDepartment of MedicineUniversity of VeronaItaly
| | - Gabriele Pesarini
- Division of CardiologyDepartment of MedicineUniversity of VeronaItaly
| | - Michele Pighi
- Division of CardiologyDepartment of MedicineUniversity of VeronaItaly
| | - Andrea Gratta
- Division of CardiologyDepartment of MedicineUniversity of VeronaItaly
| | - Leonardo Gottin
- Division of AnaesthesiologyDepartment of SurgeryUniversity of VeronaItaly
| | | | | | - Anna Piccoli
- Division of CardiologyDepartment of MedicineUniversity of VeronaItaly
| | - Valeria Ferrero
- Division of CardiologyDepartment of MedicineUniversity of VeronaItaly
| | - Flavio Ribichini
- Division of CardiologyDepartment of MedicineUniversity of VeronaItaly
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