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

Evaluation of coronary disease among patients undergoing transcatheter aortic valve implantation: propensity score matching analysis

BACKGROUND

Chronic coronary syndrome (CCS) is common among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Current guidelines recommend performance of percutaneous coronary intervention (PCI) of any > 70% proximal coronary lesions prior to TAVI.

AIMS

To evaluate the outcomes of two diagnostic approaches for CCS clearance pre-TAVI and to determine the reduction in the need of invasive angiography (IA).

METHODS

We investigated 2219 patients undergoing TAVI for severe aortic stenosis at two large centers with different pre-procedural strategies for CCS assessment: pre-TAVI computed tomography angiography (CTA) with selective invasive angiography according to CTA results or mandatory IA. We preformed propensity score matching analysis using a 1:1 ratio. The final study cohort included 870 matched patients. Peri-procedural complications were documented according to the VARC-2 criteria. Mortality rates were prospectively documented.

RESULTS

Mean age of the study population was 82 ± 7, of whom 55% were female. Patients in the IA group had significantly higher rates of pre-TAVI PCI compared to the CTA group (39% vs. 22%, p < 0.001). Following TAVI, peri-procedural myocardial infarction (MI) rates were similar between the two groups (0.3% vs. 0.7%, p value = 0.41), but spontaneous MI were significantly lower among the IA group (0% vs. 1.3%, p value = 0.03). Kaplan-Meier's survival analysis found that the cumulative probability of 1-year morality was similar between the two groups (p value log rank = 0.65). Cox regression analysis did not find association between CCS clearance strategy and outcome.

CONCLUSIONS

In elderly patients, CTA-driven approach for CCS evaluation pre-TAVI is a valid strategy with similar outcome as compared to invasive approach. CTA strategy significantly reduces invasive procedures rates without compromising patient's outcome.

The Effect of Coronary Lesion Complexity and Preprocedural Revascularization on 5-Year Outcomes After TAVR

BACKGROUND

Aortic stenosis and coronary artery disease (CAD) frequently coincide. However, the management of coexisting CAD in patients undergoing transcatheter aortic valve replacement (TAVR) remains controversial.

OBJECTIVES

This study sought to determine whether the presence of CAD, its complexity, and angiography-guided percutaneous coronary intervention (PCI) are associated with outcomes after TAVR.

METHODS

All patients undergoing TAVR at a tertiary referral center between 2008 and 2020 were included in a prospective observational study. Baseline SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score (SS) and, whenever applicable, a residual SS after PCI were calculated. A multivariate analysis was performed to determine the effect of CAD, stratified according to complexity, and PCI on 5-year outcomes.

RESULTS

In 604 patients, the presence of CAD and its complexity were significantly associated with worse 5-year survival (SS 0: 67.9% vs SS 1-22: 56.1% vs SS >22: 53.0%; log-rank P = 0.027) and increased cardiovascular mortality (SS 0: 15.1% vs SS 1-22: 24.0% vs SS >22: 27.8%; log-rank P = 0.024) after TAVR. Having noncomplex CAD (SS 1-22) was an independent predictor for increased all-cause mortality (HR: 1.43; P = 0.046), while complex CAD (SS >22) increased cardiovascular mortality significantly (HR: 1.84; P = 0.041). Angiography-guided PCI or completeness of revascularization was not associated with different outcomes.

CONCLUSIONS

The presence of CAD and its anatomical complexity in patients undergoing TAVR are associated with significantly worse 5-year outcomes. However, angiography-guided PCI did not improve outcomes, highlighting the need for further research into physiology-guided PCI.

The Role of Mechanical Circulatory Support in Patients With Severe Left Ventricular Impairment Treated With Transcatheter Aortic Valve Implantation and Percutaneous Coronary Intervention

Transcatheter aortic valve implantation (TAVI) has become an established treatment for patients with severe aortic stenosis (AS) in an ever-growing patient population. It is not uncommon for patients who are undergoing TAVI to have technically difficult anatomy, simultaneous severe left ventricular (LV) impairment and/or extensive coronary artery disease. In this case series we present examples where the use of mechanical circulatory support (MCS) facilitated a safe aortic and coronary intervention in extremely complex patients who would have otherwise carried prohibitive procedural risk.

Periprocedural myocardial injury and coronary artery disease in patients undergoing transcatheter aortic valve replacement

BACKGROUND/PURPOSE

PPMI and CAD are common in patients undergoing TAVR. Despite several studies evaluating their interaction as well as the influence these factors play on outcomes, there remains no consensus. We sought to evaluate the impact of peri-procedural myocardial injury (PPMI) and incidental coronary artery disease (iCAD) on outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).

METHODS/MATERIALS

We analyzed prospective data from 400 patients undergoing TAVI for severe aortic stenosis between 2008 and 2018 to determine rates of PPMI (troponin 15× the upper limit of normal) and iCAD (≥50% stenosis) and their impact on long-term mortality.

RESULTS

Mean age was 83 ± 6 years; 45% were female. PPMI was observed in 65% (254/400). On multivariable logistic regression analysis, higher left ventricular ejection fraction (LVEF) (OR 1.04, 95%CI 1.01-1.06, p = 0.002), and first generation valves (OR 3.00, 95%CI 1.75-5.15, p < 0.001) were independently associated with PPMI, while oral anticoagulation was inversely associated (OR 0.48, 95%CI 0.28-0.82, p = 0.007). PPMI was not associated with 30-day, 1-year or long-term mortality. After excluding previous bypass grafting, iCAD was observed in 40% (129/324). In patients with iCAD, PCI was associated with reduced long-term mortality compared to medical management in adjusted analysis (OR 0.37, 95%CI 0.16-0.88, p = 0.03).

CONCLUSIONS

PPMI and iCAD in patients undergoing TAVR are common. PPMI is associated with older generation valves and higher LVEF rather than traditional cardiovascular risk factors. In our study, PPMI was not associated with long-term mortality. However, in patients with iCAD, PCI was associated with reduced long-term mortality compared to medical management.

Aortic Valve Disease and Associated Complex CAD: The Interventional Approach

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.

Impact of Coronary Artery Disease on Outcomes in Patients Undergoing Percutaneous Edge-to-Edge Repair

OBJECTIVES

The aim of this observational study was to evaluate the impact of concomitant coronary artery disease (CAD) on outcomes in patients undergoing percutaneous valve repair with the MitraClip system.

BACKGROUND

Mitral valve regurgitation and CAD are often coexistent in elderly patients undergoing percutaneous mitral valve repair. The impact of CAD and revascularization on outcomes in this patient cohort, however, remains uncertain.

METHODS

In 444 MitraClip patients, CAD severity was assessed, represented by the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (SS), as well as the residual SS (rSS) and SYNTAX score II (SS-II). Patients were stratified according to CAD severity and SS-II values (SS ≤3 vs. SS >3 and SS-II ≤45 vs. SS-II >45) and according to remaining CAD burden into 2 groups (rSS = 0 vs. rSS >0) to compare 1-year all-cause mortality.

RESULTS

Higher SS, rSS, and SS-II were associated with mortality (22% for SS >3 vs. 9.6% for SS ≤3 [p < 0.001], 31.4% for rSS >0 vs. 9.6% for rSS = 0 [p < 0.001], and 17.1% for SS-II > 45 vs. 11.2% for SS-II ≤45 [p = 0.044]). The rSS was an independent predictor of 1-year all-cause mortality (p = 0.001) in multivariate analysis.

CONCLUSIONS

The complexity of CAD, as assessed using the SS, is associated with outcomes in patients undergoing MitraClip procedures. The burden of residual CAD after percutaneous coronary intervention is an independent predictor of 1-year all-cause mortality. Patients undergoing complete revascularization had the most favorable outcomes independent of mitral regurgitation etiology.

Impact of Incomplete Coronary Revascularization on Late Ischemic and Bleeding Events after Transcatheter Aortic Valve Replacement

BACKGROUND

The impact of coronary artery disease (CAD) and revascularization by percutaneous coronary intervention (PCI) on prognosis in patients undergoing transcatheter aortic valve replacement (TAVR) remain debated. A dismal prognosis in patients undergoing PCI has been associated with elevated baseline SYNTAX score (bSS) and residual SYNTAX score (rSS). The objective was to investigate whether the degree of bSS and rSS impacted ischemic and bleeding events after TAVR.

METHODS

bSS and rSS were calculated in 311 patients admitted for TAVR. The primary outcome was the occurrence of major adverse cardiac events (MACE), a composite endpoint of myocardial infarction, stroke, cardiovascular death, or rehospitalization for heart failure. The occurrence of late major/life-threatening bleeding complications (MLBCs) and each primary endpoint individually were the secondary endpoints.

RESULTS

bSS > 22 was associated with higher occurrence of MACE (p = 0.013). rSS > 8 and bSS > 22 had no impact on overall cardiovascular mortality. rSS > 8 and bSS > 22 were associated with higher rates of myocardial infarction (p = 0.001 and p = 0.004) and late occurrence of MLBCs. Multivariate analysis showed that bSS > 22 (sHR 2.48) and rSS > 8 (sHR 2.35) remained predictors of MLBCs but not of myocardial infarction.

CONCLUSIONS

Incomplete coronary revascularization and CAD burden did not impact overall and cardiac mortality but constitute predictors of late MLBCs in TAVR patients.

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.

Impact of Coronary Artery Severity and Revascularization Prior to Transcatheter Aortic Valve Implantation

The prevalence of coexisting coronary artery disease (CAD) is high in patients who underwent transcatheter aortic valve implantation (TAVI). Our objective was to first determine if the severity of CAD before TAVI had an important impact on post-TAVI outcomes and second, if revascularization with percutaneous coronary intervention (PCI) before TAVI modified this relation. In this retrospective population-based study in Ontario, Canada, we identified all patients with obstructive CAD who underwent TAVI from April 1, 2012 to March 31, 2017. Our primary outcomes of interest were all-cause mortality within 30-day and 1-year post-TAVI procedure. Secondary outcomes included 30-day and 1-year all-cause readmissions. We developed multivariable Cox proportional hazard models, with a robust sandwich-type variance estimator to account for clustering within TAVI centers. These models included an interaction term between severity of CAD and PCI before TAVI. The study cohort included 888 of whom 444 (50%) patients underwent PCI before TAVI procedure. In the Cox models, we found that severity of CAD before TAVI was not significantly associated with post-TAVI outcomes. The only exception was 1 to 2 vessel/s disease which was a significant predictor of 1-year readmission. Pre-TAVI PCI was not significantly associated with outcomes, nor did it modify the relation between severity of CAD pre-TAVI and outcomes. In conclusion, we did not find a consistent relation between severity of CAD and revascularization with post-TAVI outcomes.

Comparison of Survival of Transfemoral Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement for Aortic Stenosis in Low-Risk Patients Without Coronary Artery Disease

Increasing data support transcatheter aortic valve implantation (TAVI) as a valid option over surgical aortic valve replacement (SAVR) in the treatment for severe aortic stenosis (AS) also in patients with low operative risk. However, limited data exist on the outcome of TAVI and SAVR in low-risk patients without coronary artery disease (CAD). The FinnValve registry included data on 6463 patients who underwent TAVI or SAVR with bioprosthesis between 2008 and 2017. Herein, we evaluated the outcome of low operative risk as defined by STS-PROM score <3% and absence of CAD, previous stroke and other relevant co-morbidities. Only patients who underwent TAVI with third-generation prostheses and SAVR with Perimount Magna Ease or Trifecta prostheses were included in this analysis. The primary endpoints were 30-day and 3-year all-cause mortality. Overall, 1,006 patients (175 TAVI patients and 831 SAVR patients) met the inclusion criteria of this analysis. Propensity score matching resulted in 140 pairs with similar baseline characteristics. Among these matched pairs, 30-day mortality was 2.1% in both TAVI and SAVR cohorts (p = 1.00) and 3-year mortality was 17.0% after TAVI and 14.6% after SAVR (p = 0.805). Lower rates of bleeding and atrial fibrillation, and shorter hospital stay were observed after TAVI. The need of new permanent pacemaker implantation and the incidence of early stroke did not differ between groups. In conclusion, TAVI using third-generation prostheses achieved similar early and mid-term survival compared with SAVR in low-risk patients without CAD.

Short-term LPS induces aortic valve thickening in ApoE*3Leiden mice

BACKGROUND

Recently, it was shown that 12 weeks of lipopolysaccharide (LPS) administration to nonatherosclerotic mice induced thickening of the aortic heart valve (AV). Whether such effects may also occur even earlier is unknown. As most patients with AV stenosis also have atherosclerosis, we studied the short-term effect of LPS on the AVs in an atherosclerotic mouse model.

METHODS

ApoE*3Leiden mice, on an atherogenic diet, were injected intraperitoneally with either LPS or phosphate buffered saline (PBS), and sacrificed 2 or 15 days later. AVs were assessed for size, fibrosis, glycosaminoglycans (GAGs), lipids, calcium deposits, iron deposits and inflammatory cells.

RESULTS

LPS injection caused an increase in maximal leaflet thickness at 2 days (128.4 µm) compared to PBS-injected mice (67.8 µm; P = 0.007), whereas at 15 days this was not significantly different. LPS injection did not significantly affect average AV thickness on day 2 (37.8 µm), but did significantly increase average AV thickness at day 15 (41.6 µm; P = 0.038) compared to PBS-injected mice (31.7 and 32.3 µm respectively). LPS injection did not affect AV fibrosis, GAGs and lipid content. Furthermore, no calcium deposits were found. Iron deposits, indicative for valve haemorrhage, were observed in one AV of the PBS-injected group (a day 2 mouse; 9.1%) and in five AVs of the LPS-injected group (both day 2- and 15 mice; 29.4%). No significant differences in inflammatory cell infiltration were observed upon LPS injection.

CONCLUSION

Short-term LPS apparently has the potential to increase AV thickening and haemorrhage. These results suggest that systemic inflammation can acutely compromise AV structure.

Impact of Coronary Revascularization in Patients Who Underwent Transcatheter Aortic Valve Implantation

Coronary artery disease (CAD) is a common co-morbidity in transcatheter aortic valve implantation (TAVI) patients, but the prognostic value of coronary revascularization before TAVI is currently unknown. The aim of the present study was to assess the impact of coronary revascularization in patients who underwent TAVI. Patients underwent TAVI from 2008 to 2016 were included in the study. Baseline SYNTAX score and residual SYNTAX score (rSS) after percutaneous coronary intervention were calculated. Based on rSS, patients were classified as complete revascularization (rSS = 0), reasonably incomplete revascularization (rSS >0 and <8), and incomplete revascularization (rSS ≥8). The primary objective was to evaluate the impact of CAD and rSS on major cardiovascular adverse events (MACEs). The secondary objective was to assess the impact of rSS on hospitalization for heart failure. A total of 349 patients (mean age 82.4 ± 5.7 years, 53% women) were included in the study. A total of 187 patients (53.6%) had CAD (mean baseline SYNTAX score 9.2 ± 8.1). Percutaneous coronary intervention was performed in 29.9% of patients, achieving reasonably incomplete revascularization in 45.4%, and incomplete revascularization in 24.5%. The mean follow-up was 35.2 ± 25.3 months. No differences were observed in MACE rate between the CAD and non-CAD groups, or between the different degrees of revascularization. Differences were also not seen in the different levels of revascularization and hospitalization due to heart failure. In patients who underwent TAVI in this study, no association was found between the presence of CAD or the degree of revascularization in a long-term follow-up.

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.

CAD strategy in the TAVR era

The optimal revascularization strategy for CAD in the TAVR population is not well-defined and decisions about which patients require PCI have been largely operator dependent or based on SYNTAX score. In a TAVR population, complete revascularization does not improve short or long term mortality, but is associated with decreased acute myocardial infarction and revascularization, when compared with incomplete revascularization. Future prospective studies should evaluate revascularization strategies in TAVR patients, including considering functional lesion assessment with fractional flow reserve, especially as TAVR indications are likely to soon expand to a younger and healthier cohort.

CTCA for detection of significant coronary artery disease in routine TAVI work-up : A systematic review and meta-analysis

Transcatheter aortic valve implantation (TAVI) has evolved to standard treatment of severe aortic stenosis in patients with an intermediate to high surgical risk. Computed tomography coronary angiography (CTCA) could partially replace invasive coronary angiography to diagnose significant coronary artery disease in the work-up for TAVI. A literature search was performed in MEDLINE and EMBASE for papers comparing CTCA and coronary angiography in TAVI candidates. The primary endpoint was the diagnostic accuracy of CTCA, compared to coronary angiography, for detection of significant (>50% diameter stenosis) coronary artery disease, measured as sensitivity, specificity, positive—(PPV) and negative predictive value (NPV). Seven studies were included, with a cumulative sample size of 1,275 patients. The patient-based pooled sensitivity, specificity, PPV and NPV were 95, 65, 71 and 94% respectively. Quality assessment revealed excellent and good quality in terms of applicability and risk of bias respectively, with the main concern being patient selection. In conclusion, on the basis of a significance cut-off value of 50% diameter stenosis, CTCA provides acceptable diagnostic accuracy for the exclusion of coronary artery disease in patients referred for TAVI. Using the routinely performed preoperative computed tomography scans as a gatekeeper for coronary angiography could decrease additional coronary angiographies by 37% in this high-risk and fragile population.

Impact of Coronary Artery Revascularization Completeness on Outcomes of Patients With Coronary Artery Disease Undergoing Transcatheter Aortic Valve Replacement

Background—

Coronary artery disease (CAD) is highly prevalent in patients undergoing transcatheter aortic valve replacement. In the overall CAD population, complete revascularization or reasonable incomplete revascularization (ICR) is associated with improved outcomes; whether the same applies for the transcatheter aortic valve replacement population is still a matter of debate.

Methods and Results—

We conducted a systematic review and meta-analysis of studies that examined the prognostic effect of revascularization completeness in patients undergoing transcatheter aortic valve replacement using the residual SYNTAX score (Synergy Between PCI With Taxus and Cardiac Surgery) to separate between reasonable ICR and ICR (using the individual threshold used by each study). Six studies with a total of 3107 patients were included. The duration of follow-up ranged from 0.7 to 3 years. Overall, ICR was associated with an increased risk for mortality. This was true when comparing ICR patients to those with no CAD (odds ratio, 1.85; 95% confidence interval, 1.42–2.40; P <0.01), to those with reasonable ICR (odds ratio, 1.69; 95% confidence interval, 1.26–2.28; P <0.001), or to both groups combined (odds ratio, 1.71; 95% confidence interval, 1.36–2.16; P <0.001). On the contrary, patients in the reasonable ICR category did not show an increased risk for mortality when compared with those with no CAD (odds ratio, 1.11; 95% confidence interval, 0.89–1.39; P =0.33).

Conclusions—

Our results suggest that for patients with CAD undergoing transcatheter aortic valve replacement, a residual SYNTAX score–guided revascularization strategy may carry significant benefits in terms of mortality. Adequate revascularization may offer a unique and valuable opportunity to improve the prognosis of these patients.

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.