Coronary artery disease and its management: influence on survival in patients undergoing aortic valve replacement

Feasibility and Safety of Post-Transcatheter Aortic Valve Replacement Coronary Revascularization Guided by Stress Cardiac Imaging

Background: Systematic revascularization of asymptomatic coronary artery stenosis before transcatheter aortic valve replacement (TAVR) is controversial. Purpose: The purpose of this study was to evaluate the feasibility and safety of functional evaluation of coronary artery disease (CAD) followed by selective ischemia-guided percutaneous coronary revascularization following TAVR. Methods: This prospective, bi-centric, single-arm, open-label trial included all patients with severe aortic stenosis (AS) eligible for TAVR and with significant CAD defined as ≥1 coronary stenosis ≥ 70%. Patients with left main stenosis ≥ 50%, proximal left anterior descending artery (LAD) stenosis ≥ 90% or > class 2 Canadian Classification Society (CCS) angina were excluded. Myocardial ischemia was evaluated by stress cardiac imaging one month after TAVR. The primary endpoint was a composite of all-cause death, stroke, major bleeding (Bleeding Academic Research Consotium ≥ 3), major vascular complication (Valve Academic Research Consortium 3 criteria), acute coronary syndrome (ACS) and hospitalization for cardiac causes within 6 months of receiving TAVR. Results: Between June 2020 and June 2022, 64 patients were included in this study. The mean age was 84 ± 5.2 years. CAD mostly involved LAD (n = 27, 42%) with frequent multivessel disease (n = 30, 47%) and calcified lesions (n = 39, 61%). Stress cardiac imaging could be achieved in 70% (n = 46) of the patients, while 30% (n = 18) did not attend the stress test. Significant myocardial ischemia was observed in only three patients (4.5%). At 6-month follow-up, fifteen patients (23%) reached the primary endpoint, including death in six patients (9%), stroke in three patients (5%) and major bleeding in three patients (5%). ACS was observed in only two patients (3%) but both had severe coronary stenosis (≥90%) and did not refer for stress imaging for personal reasons. Hospital readmission (n = 27, 41%) was mostly related to non-cardiac causes (n = 17, 27%). Conclusions: In patients with asymptomatic CAD scheduled to undergo TAVR, a selective ischemia-guided coronary revascularization after TAVR seems to be safe, with a very low rate of ACS and few cases of myocardial ischemia requiring revascularization, despite low adherence to medical follow-up in this elderly population. This strategy could be evaluated in a randomized study.

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.

Trends and outcomes of concomitant aortic valve replacement and coronary artery bypass grafting in the UK and a survey of practices

OBJECTIVES

Concomitant revascularization of coronary artery disease at the same time as treatment for aortic valvopathy favourably impacts survival. However, combined surgery may be associated with increased adverse outcomes compared to aortic valve replacement (AVR) or coronary artery bypass grafting in isolation.

METHODS

We retrospectively analyzed all patients who underwent AVR with bypass grafting between February 1996 and March 2019 using data from the National Adult Cardiac Surgery Audit. We used a generalized mixed-effects model to assess the effect of the number and type of bypass grafts associated with surgical AVR on in-hospital mortality, postoperative stroke, and the need for renal dialysis. Furthermore, we conducted an international cross-sectional survey of cardiac surgeons to explore their views about concomitant AVR with coronary bypass grafting interventions.

RESULTS

Fifty-one thousand two hundred and seventy-two patients were included in the study. Patients receiving 2 or more bypass grafts demonstrated more significant preoperative comorbidity and disease severity. Patients undergoing 2 and >2 grafts in addition to AVR had increased mortality as compared to patients undergoing AVR and only 1 graft [odds ratio (OR) 1.17, 95% confidence interval (CI) [1.05-1.30], P = 0.005 and OR 1.15, 95% CI [1.02-1.30], P = 0.024 respectively]. A single arterial conduit was associated with a reduction in mortality (OR 0.75, 95% CI [0.68-0.82], P < 0.001) and postoperative dialysis (OR 0.87, 95% CI [0.78-0.96], P = 0.006), but this association was lost with >1 arterial conduit. One hundred and three surgeons responded to our survey, with only a small majority believing that the number of bypass grafts can influence short- or long-term postoperative outcomes in these patients, and an almost equal split in responders supporting the use of staged or hybrid interventions for patients with concomitant pathology.

CONCLUSIONS

The number of grafts performed during combined AVR and coronary artery bypass grafting is associated with increased morbidity and mortality. The use of an arterial graft was also associated with reduced mortality. Future studies are needed to assess the effect of incomplete revascularization and measure long-term outcomes. Based on our data, current published evidence, and the collective expert opinion we gathered, we endorse future work to investigate the short and long-term efficacy and safety of hybrid intervention for patients with concomitant advanced coronary and aortic valve disease.

Aortic Stenosis Phenotypes and Precision Transcatheter Aortic Valve Implantation

Patients with a clinical indication for aortic valve replacement can either undergo surgical aortic valve replacement (SAVR) or Transcatheter Aortic Valve Implantation (TAVI). There are many different factors that go into determining which type of replacement to undergo, including age, life expectancy, comorbidities, frailty, and patient preference. While both options offer significant benefits to patients in terms of clinical outcomes and quality of life, there is growing interest in expanding the indications for TAVI due to its minimally invasive approach. However, it is worth noting that there are several discrepancies in TAVI outcomes in regards to various endpoints, including death, stroke, and major cardiovascular events. It is unclear why these discrepancies exist, but potential explanations include the diversity of etiologies for aortic stenosis, complex patient comorbidities, and ongoing advancements in both medical therapies and devices. Of these possibilities, we propose that phenotypic variation of aortic stenosis has the most significant impact on post-TAVI clinical outcomes. Such variability in phenotypes is often due to a complex interplay between underlying comorbidities and environmental and inherent patient risk factors. However, there is growing evidence to suggest that patient genetics may also play a role in aortic stenosis pathology. As such, we propose that the selection and management of TAVI patients should emphasize a precision medicine approach.

Management of coronary artery disease in patients with aortic stenosis in the era of transcatheter aortic valve replacement

Aortic stenosis (AS) is a common valve disorder among the elderly, and these patients frequently have concomitant coronary artery disease (CAD). Risk factors for calcific AS are similar to those for CAD. Historically, the treatment of these conditions involved simultaneous surgical replacement of the aortic valve (AV) with coronary artery bypass grafting. Since the advancement of transcatheter AV therapies, there have been tremendous advancements in the safety, efficacy, and feasibility of this procedure with expanding indications. This has led to a paradigm shift in our approach to the patient with AS and concomitant CAD. Data regarding the management of CAD in patients with AS are largely limited to single-center studies or retrospective analyses. This article aims to review available literature around the management of CAD in patients with AS and assist in the current understanding in approaches toward management.

Comparison of First-generation and Third-generation Dual-source Computed Tomography for Detecting Coronary Artery Disease in Patients Evaluated for Transcatheter Aortic Valve Replacement

PURPOSE

This study compared image quality and evaluability of coronary artery disease (CAD) in routine preparatory imaging for transcatheter aortic valve replacement using 64-slice (first-generation) to 192-slice (third-generation) dual-source computed tomography(DSCT).

MATERIALS AND METHODS

The CT data sets of 192 patients (122 women, median age 82 y) without severe renal dysfunction or known CAD were analyzed retrospectively. Half were examined using first-generation DSCT (June 2014 to February 2016) and the other half with third-generation DSCT (April 2016 to April 2017). Per protocol, contrast material (110 [110 to 120] vs. 70 [70 to 70] mL, P <0.001) and radiation dose of multiphasic retrospectively gated thoracic CT angiography (dose-length-product, 1001 [707 to 1312] vs. 727 [474 to 1369] mGy×cm, P <0.001) were significantly lower with third-generation DSCT. Significant CAD was defined as CAD-RADS ≥4 by CT. Invasive coronary angiography served as the reference standard (CAD is defined as ≥70% stenosis or fractional flow reserve ≤0.80).

RESULTS

In comparison with first-generation DSCT, third-generation DSCT showed significantly better subjective (3 [interquartile range 2 to 3] vs. 4 [3 to 4.25] on a 5-point scale, P <0.001) and objective image quality (signal-to-noise ratio of left coronary artery 12.8 [9.9 to 16.4] vs. 15.2 [12.4 to 19.0], P <0.001). Accuracy (72.9% vs. 91.7%, P =0.001), specificity (59.7% vs. 88.3%, P <0.001), positive (61.0% vs. 83.3%, P <0.001), and negative predictive value (91.9% vs. 98.2%, P =0.045) for detecting CAD per-patient were significantly better using third-generation DSCT, while sensitivity was similar (92.3% vs. 97.2%, P =0.129).

CONCLUSIONS

Coronary artery evaluation with CT angiography before TAVI is feasible in selected patients. Compared with first-generation DSCT, state-of-the-art third-generation DSCT technology is superior for this purpose, allowing for less contrast medium and radiation dose while providing better image quality and improved diagnostic performance.

Management of coronary artery disease in patients with aortic stenosis

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

Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis

More than half of patients with severe aortic stenosis (AS) over 70 years old have coronary artery disease (CAD). Exertional angina is often present in AS-patients, even in the absence of significant CAD, as a result of oxygen supply/demand mismatch and exercise-induced myocardial ischemia. Moreover, persistent myocardial ischemia leads to extensive myocardial fibrosis and subsequent coronary microvascular dysfunction (CMD) which is defined as reduced coronary vasodilatory capacity below ischemic threshold. Therefore, angina, as well as noninvasive stress tests, have a low specificity and positive predictive value (PPV) for the assessment of epicardial coronary stenosis severity in AS-patients. Moreover, in symptomatic patients with severe AS exercise testing is even contraindicated. Given the limitations of noninvasive stress tests, coronary angiography remains the standard examination for determining the presence and severity of CAD in AS-patients, although angiography alone has poor accuracy in the evaluation of its functional severity. To overcome this limitation, the well-established invasive indices for the assessment of coronary stenosis severity, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), are now in focus, especially in the contemporary era with the rapid increment of transcatheter aortic valve replacement (TAVR) for the treatment of AS-patients. TAVR induces an immediate decrease in hyperemic microcirculatory resistance and a concomitant increase in hyperemic flow velocity, whereas resting coronary hemodynamics remain unaltered. These findings suggest that FFR may underestimate coronary stenosis severity in AS-patients, whereas iFR as the non-hyperemic index is independent of the AS severity. However, because resting coronary hemodynamics do not improve immediately after TAVR, the coronary vasodilatory capacity in AS-patients treated by TAVR remain impaired, and thus the iFR may overestimate coronary stenosis severity in these patients. The optimal method for evaluating myocardial ischemia in patients with AS and co-existing CAD has not yet been fully established, and this important issue is under further investigation. This review is focused on challenges, limitations, and future perspectives in the functional assessment of coronary stenosis severity in these patients, bearing in mind the complexity of coronary physiology in the presence of this valvular heart disease.

Revascularization in the Transcatheter Aortic Valve Replacement Population

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

Aortic Stenosis and Coronary Artery Disease: Cost of Transcatheter versus Surgical Management

BACKGROUND

Surgical aortic valve replacement with coronary artery bypass grafting (SAVR+CABG) is the recommended treatment for aortic stenosis (AS) and coronary artery disease (CAD), however percutaneous coronary intervention at the time of transcatheter aortic valve replacement (TAVR+PCI) is used with increasing frequency.

METHODS

Using the National Inpatient Sample, we identified all adult admissions with a diagnosis of AS. Sub-groups of SAVR+CABG and TAVR+PCI formed the study group. Outcomes of interest included total hospitalization charges, temporal trends, in-hospital mortality, and complications.

RESULTS

Between 2012 and 2017, a total of 97,955 (95.9%) admissions received SAVR+CABG, and 4240 (4.1%) received TAVR+PCI; the proportion of TAVR+PCI increased from 1.0% in 2012 to 9.2% in 2017 (p<0.001). Compared to those receiving TAVR+PCI, admissions receiving SAVR+CABG were younger, more likely to be male, and had lower comorbidity (all p<0.001). Adjusted in-hospital mortality was comparable in both groups (OR 0.94, 95% CI 0.79-1.11, p=0.45). Higher rates of pacemaker implantation, cardiac arrest, and vascular complications were seen in the TAVR+PCI group, while SAVR+CABG was associated with a greater requirement of prolonged ventilation. Admissions receiving TAVR+PCI had shorter lengths of hospital stay and were more likely to be discharged home. Nevertheless, TAVR+PCI had higher hospitalization charges compared to SAVR+CABG group (all p<0.001).

CONCLUSIONS

There has been a steady increase in the utilization of percutaneous strategies for AS and CAD management. In-hospital mortality was comparable in SAVR+CABG and TAVR+PCI groups, but despite shorter in-hospital stays, TAVR+PCI was associated with higher cardiac and vascular complication rates and hospitalization charges.

Role of coronary angiogram before transcatheter aortic valve implantation

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Role of Concomitant Coronary Artery Bypass Grafting in Valve Surgery for Infective Endocarditis

BACKGROUND

It is current practice to perform concomitant coronary artery bypass grafting (CABG) in patients with infective endocarditis (IE) who have relevant coronary artery disease (CAD). However, CABG may add complexity to the operation. We aimed to investigate the impact of concomitant CABG on perioperative outcomes in patients undergoing surgery for IE.

METHODS

We retrospectively used data of surgically treated IE patients between 1994 and 2018 in six German cardiac surgery centers. We performed inverse probability weighting (IPW), multivariable adjustment, chi-square analysis, and Kaplan-Meier survival estimates.

RESULTS

CAD was reported in 1242/4917 (25%) patients. Among them, 527 received concomitant CABG. After adjustment for basal characteristics between CABG and no-CABG patients using IPW, concomitant CABG was associated with higher postoperative stroke (26% vs. 21%, p = 0.003) and a trend towards higher postoperative hemodialysis (29% vs. 25%, p = 0.052). Thirty-day mortality was similar in both groups (24% vs. 23%, p = 0.370). Multivariate Cox regression analysis after IPW showed that CABG was not associated with better long-term survival (HR: 1.00, 95% CI: 0.82-1.23, p = 0.998).

CONCLUSION

In endocarditis patients with CAD, adding CABG to valve surgery may be associated with a higher likelihood of postoperative stroke without adding long-term survival benefits. Therefore, in the absence of critical CAD, concomitant CABG may be omitted without impacting outcome. The results are limited due to a lack of data on the severity of CAD, and therefore there is a need for a randomized trial.

Impact of Coronary Artery Disease and Percutaneous Coronary Intervention on Transcatheter Aortic Valve Implantation

Introduction

The prevalence of coronary artery disease (CAD) detected in preoperative work-up for transcatheter aortic valve implantation (TAVI) is high. Instead, the management of a concomitant CAD remains unclear. We evaluate the impact of CAD and percutaneous coronary intervention (PCI) on TAVI procedures.

Materials and Methods

A retrospective study was conducted on 1336 consecutive patients who underwent TAVI in Toulouse University Hospital, Rangueil, France. The studied population was divided into 2 groups: CAD-TAVI group and No CAD-TAVI group. Then, the CAD-TAVI group was segregated into 2 subgroups: PCI-TAVI group and No PCI-TAVI group. In-hospital adverse clinical outcomes were assessed in each group.

Results

Pre-TAVI work-up revealed significant CAD in 36% of 1030 patients eligible for inclusion in the study. The overall prevalence of in-hospital death, stroke, major or life-threatening bleeding, minor bleeding, major vascular complications, minor vascular complications, pacemaker implantation, and acute kidney injury was 2.7%, 2.4%, 2.8%, 3.6%, 3.9%, 7.5%, 12.5%, and 2.7%, respectively. Among the studied population, 55% were admitted to the cardiac care unit. No significant statistical difference was observed between groups. Discussion. CAD-TAVI population was not more likely to develop in-hospital adverse clinical outcomes post-TAVI procedure compared to others. Also, no significant difference regarding in-hospital death was observed. In parallel, performing PCI prior to TAVI did not increase the risk of in-hospital death and complications. The difference in terms of the distribution of antithrombotic regimen may explain the higher prevalence of bleeding events in the PCI-TAVI group.

Conclusion

This study provides direct clinical relevance useful in daily practice. No negative impact has been attributed to the presence of a concomitant CAD and/or preoperative PCI on the TAVI hospitalization period.

Evaluation of Routine Coronary Angiography Before Pulmonary Thromboendarterectomy

BACKGROUND

At the University of California, San Diego, routine coronary angiography has generally been performed in men 40 years of age and older and women 45 years of age and older before pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension (CTEPH). The prevalence of significant coronary artery disease (CAD) in this population has not been evaluated, however, and the optimal screening strategy has not been established. This study sought to evaluate whether the current approach may be better optimized on the basis of cardiac risk factors.

METHODS

This study included 462 consecutive patients with CTEPH who were undergoing preoperative coronary angiography for pulmonary thromboendarterectomy. Baseline demographic and medical information was recorded. Major cardiac risk factors included: diabetes, hypertension, hyperlipidemia, body mass index 25 kg/m² or greater, tobacco use, and family history of CAD. Charts were then reviewed for presence of significant CAD and revascularization.

RESULTS

Significant CAD was found in 13.4% of patients who underwent routine preoperative coronary angiography; it was present in only 5% of patients younger than 50 years of age, compared with 16% of patients 50 years old and older. No patient younger than 50 years of age without cardiac risk factors was found to have significant CAD. Furthermore, in patients younger than 50 years of age, significant CAD was found only among those with 3 or more major risk factors.

CONCLUSIONS

In patients younger than 50 years of age with CTEPH, the prevalence of significant CAD was low. Omitting preoperative coronary angiography in this subset of patients is reasonable when no coronary risk factors are present. Preoperative coronary angiography is warranted in individuals 50 years of age and older, as well as in those younger than 50 years who have significant risk factors for CAD.

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.

Transcatheter aortic valve replacement and percutaneous coronary intervention versus surgical aortic valve replacement and coronary artery bypass grafting in patients with severe aortic stenosis and concomitant coronary artery disease: A systematic review and meta-analysis

OBJECTIVES

We performed a systematic review and meta-analysis to evaluate the early and midterm outcomes of patients who underwent surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) against patients who had transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI).

BACKGROUND

Contemporary guidelines suggest that surgical or percutaneous revascularization of significant coronary artery disease (CAD) in patients with severe aortic stenosis (AS) is a reasonable strategy.

METHODS

We conducted a comprehensive search of Medline and Embase to identify studies comparing a percutaneous transcatheter versus a surgical approach. Random effects meta-analyses using the Mantel-Haenszel method were performed to estimate the effect of percutaneous compared surgical strategies using aggregate data.

RESULTS

Six studies reporting on 1770 participants were included in the meta-analysis. There were no significant differences in effect estimates for early and midterm mortality (OR: 0.78; 95% CI, 0.50-1.20 and OR: 1.09; 95% CI, 0.80-1.49, respectively) or myocardial infarction (OR: 0.52; 95% CI, 0.20-1.33 and OR: 1.34; 95% CI, 0.67-2.65, respectively). No significant difference was shown for peri-procedural stroke (OR: 0.80; 95% CI, 0.35-1.87). A transcatheter approach had a higher rate of major vascular complications (OR: 14.44; 95% CI, 4.42-47.16), but a lower rate of acute kidney injury (OR: 0.41; 95% CI, 0.19-0.91).

CONCLUSION

Our analysis suggests that a percutaneous transcatheter approach confers similar outcomes compared to a surgical approach in patients with severe AS and CAD. However, our findings are based on low quality studies and should serve as hypothesis generating. In the absence of adequately powered studies yielding high level evidence, individualized decision making should be based on surgical risk assessment.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Angiographic Functional Scoring of Coronary Artery Disease Predicts Mortality in Patients With Severe Aortic Stenosis Undergoing TAVR

BACKGROUND/PURPOSE

Coronary artery disease (CAD) is common in patients undergoing transcatheter aortic valve replacement (TAVR), although its prognostic significance is questionable. Significant CAD stratified using SYNTAX score (SS) has been associated with greater mortality, yet it is unknown whether the functional impact of CAD also impacts outcomes in this cohort. DILEMMA score (DS) is a validated angiographic functional scoring tool that correlates with fractional flow reserve and instantaneous wave-free ratio. This study sought to assess the functional impact of CAD on outcomes in patients undergoing TAVR for severe aortic stenosis (AS).

METHODS/MATERIALS

229 patients were included in this analysis. Patients underwent angiographic DS and SS and were classified using predefined values. The primary endpoint was one-year all-cause mortality, with secondary endpoints of 30-day major adverse cardiac and cerebrovascular events (MACCE).

RESULTS

The mean age was 83.9 ± 0.5 years (55.0% female), with 11.8% all-cause mortality. CAD defined by ≥30% stenosis in any vessel was not associated with adverse outcomes (HR = 1.08, p = 0.84). However, the risk of one-year mortality was greater in patients with either SS > 9 (20.8% vs. 9.4%, HR 2.34, p = 0.03) or DS > 2 (18.4% vs. 8.5%, HR = 2.28, p = 0.03). Both scoring systems were also associated with 30-day MACCE (both p < 0.05). After multivariate adjustment, independent predictors of one-year mortality were DS > 2 (HR = 2.29, p = 0.04), left ventricular ejection fraction <50% (HR 2.66, p = 0.04) and COPD (HR 2.43, p = 0.04).

CONCLUSION

Our results demonstrate that angiographic functional scoring is independently predictive of both 12-month mortality and 30-day MACCE following TAVR.

Impact of social deprivation on outcome following transcatheter aortic valve implantation (TAVI)

Objectives

We sought to evaluate whether socioeconomic status influences outcome after first-time transcatheter aortic valve implantation (TAVI).

Method

This is a single-centre study carried out in Swansea, South West Wales, UK between 5 November 2009 and 10 June 2018. Data included age, gender, domiciliary postal code, comorbidities, complications post-TAVI, length of stay, follow-up time and survival status. The Welsh Index of Multiple Deprivation, 2014 was used to stratify cases by level of social deprivation according to domiciliary postal codes.

Results

Study population was 387 patients of whom 213 (54.8%) were men with mean age ±SD of 82.8±8.3 years. Patients, who were less deprived (296 (76.4%)), were more likely to be older (83.5±7.9 vs 80.4±9.3, p<0.05) and to be married (83.2% vs 69.7%, p<0.05). Conversely, 'more deprived' patients (91 (23.6%)) were more likely to have a longer stay in hospital as compared with patients in the 'less deprived group' (29.6±32.7 days vs 21.3±21.1 days, p<0.05). However, 30-day, 1-year and 3-year survival/mortality rates were similar across all socioeconomic levels.

Conclusions

This is the first study in which social deprivation has been investigated as a risk factor for mortality in a high-risk group of patients with severe aortic stenosis undergoing TAVI. Residing in a 'more deprived' area in South West Wales is not associated with adverse outcome following TAVI but patients who are 'more deprived' tend to stay longer in hospital compared with patients who are 'less deprived'.

Outcomes after aortic valve replacement for aortic valve stenosis, with or without concomitant coronary artery bypass grafting

OBJECTIVES

To assess the effects of concomitant coronary artery bypass grafting (CABG), we analyzed the outcomes after aortic valve replacement (AVR) for aortic stenosis (AS) with and without coronary artery bypass grafting (CABG) at our institution.

METHODS

Between 2002 and 2014, 605 consecutive patients underwent AVR for AS. Of these, the 275 who received isolated AVR (Group A) and the 122 who received both AVR and CABG (Group AC) patients were enrolled, after the exclusion of 8 patients who underwent reoperation and 200 who received other concomitant surgery. AVR and all bypass anastomoses were performed under intermittent retrograde cold blood cardioplegia. Multivariate analysis was used to assess any association of concomitant CABG with morbidity and mortality. Kaplan-Meier analysis was used to assess all-cause mortality.

RESULTS

No significant difference in 30-day mortality was found between Group A and Group AC (1.5% vs. 0.8%, P = 1.000). Nor did post-discharge survival differ significantly between the two groups (P = 0.20). Likewise, multivariate analysis showed that concomitant CABG was not associated with significantly greater in-hospital or mid-term mortality. Operative morbidities were comparable between the two groups, in terms of stroke (1.8% vs. 3.3%, P = 0.466), prolonged ventilation (4.0% vs. 5.5%, P = 0.565), deep sternal infection (1.8% vs. 3.3%, P = 0.466), and acute renal failure (0.4% vs. 1.6% P = 0.176).

CONCLUSIONS

Concomitant CABG at the time of AVR was performed without increasing early- or mid-term mortality. This absence of increased risk deserves consideration when choosing between different treatment strategies.

Coronary computed tomography angiography detection of short- and long-term outcomes after heart valve surgery with high risk cardiovascular patients

Coronary computed tomography angiography (CCTA) is a promising alternative technique to detect significant coronary artery lesions in high-risk cardiovascular patients with left ventricular dysfunction (left ventricular ejection fractions < 40%) referred for elective valve surgery, while little research about the use of CCTA to detect the outcomes of heart valve surgery was performed. Forty-six consecutive high-risk cardiovascular patients with the New York Heart Association (NYHA) classification were retrospectively studied. Immediate, 10-week, 20-week, and 40-week outcomes after heart valve surgery were assessed with CCTA. Patients' average age at the time of surgery was 73 years, with the majority being male (54.35%). Among the CCTA parameters detected after 10, 20, and 40 weeks after heart valve surgery, only segment involvement score (SIS) did reach statistical significance when compared with baseline levels. The cumulative mortality rate at 10, 20, and 40 weeks were 19.56%, 30.43%, and 39.13% respectively. It can be seen that the early death is mainly due to complications, and with the time-lapse of surgery, the impact of complications on death is gradually eliminated. CCTA might be a useful tool to detect the outcomes of short- and long-term outcomes after heart valve surgery with high risk cardiovascular patients, and SIS level is associated with the short- and long-term outcomes.

A prediction score for significant coronary artery disease in Chinese patients ≥50 years old referred for rheumatic valvular heart disease surgery

OBJECTIVES

Our goal was to establish a prediction score and protocol for the preoperative prediction of significant coronary artery disease (CAD) in patients with rheumatic valvular heart disease.

METHODS

Using multivariate logistic regression analysis, we validated the model based on 490 patients without a history of myocardial infarction and who underwent preoperative screening coronary angiography. Significant CAD was defined as ≥50% narrowing of the diameter of the lumen of the left main coronary artery or ≥70% narrowing of the diameter of the lumen of the left anterior descending coronary artery, left circumflex artery or right coronary artery.

RESULTS

Significant CAD was present in 9.8% of patients. Age, smoking, diabetes mellitus, diastolic blood pressure, low-density lipoprotein cholesterol and ischaemia evident on an electrocardiogram were independently associated with significant CAD and were entered into the multivariate model. According to the logistic regression predictive risk score, preoperative coronary angiography is recommended in (i) postmenopausal women between 50 and 59 years of age with ≥9.1% logistic regression predictive risk score; (ii) postmenopausal women who are ≥60 years old with a logistic regression predictive risk score ≥6.6% and (iii) men ≥50 years old whose logistic regression predictive risk score was ≥2.8%. Based on this predictive model, 246 (50.2%) preoperative coronary angiograms could be safely avoided. The negative predictive value of the model was 98.8% (246 of 249).

CONCLUSIONS

This model was accurate for the preoperative prediction of significant CAD in patients with rheumatic valvular heart disease. This model must be validated in larger cohorts and various populations.

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.

Staged High-Risk Percutaneous Coronary Intervention with Impella Support after On-Pump Transcatheter Aortic Valve Replacement

The management of concomitant obstructive coronary artery disease and severe aortic stenosis in poor surgical candidates is an evolving topic. Although the typical current practice is to perform percutaneous revascularization before transcatheter aortic valve replacement (TAVR), some data have emerged regarding revascularization after performing TAVR. We present the case of a 90-year-old man with multivessel coronary artery disease who was at prohibitive risk for surgical aortic valve replacement. We first performed TAVR with use of hemodynamic support, then Impella-assisted multivessel percutaneous coronary intervention on the patient's unprotected left main coronary artery. We describe this complex case and review the medical literature on percutaneous coronary intervention after TAVR.

The effect of coronary artery disease defined by quantitative coronary angiography and SYNTAX score upon outcome after transcatheter aortic valve implantation (TAVI) using the Edwards bioprosthesis

AIMS

We sought to evaluate the effects of significant coronary artery disease (CAD) upon outcome after transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

We performed a retrospective study of 271 consecutive patients undergoing TAVI using either the Edwards SAPIEN or Edwards SAPIEN XT valve. Pre-procedural coronary angiograms were analysed by quantitative coronary angiography (defining significant CAD as a stenosis of ≥70% or ≥50% if in the left main stem or a vein graft). Ninety-three out of 271 patients had significant CAD. There was no difference in mortality at 30 days or 12 months between the two groups (6.7% vs. 7.5% and 21.5% vs. 23.7%; log-rank p=0.805). A secondary analysis using the SYNTAX algorithm of coronary anatomy complexity was performed on 189 patients. Those in the high SYNTAX score (>33) group had higher mortality at 30 days and 12 months (14.3% and 57.1%) than the low (5.2% and 23.3%) and intermediate-risk groups (11.1% and 22.2%; log-rank p=0.007). ROC analysis identified a SYNTAX score of >9 at the time of TAVI as the optimal cut-off, with an independent association with mortality (HR 1.95 [95% CI: 1.21-3.13]; p=0.006). Patients with a SYNTAX score >9 had greater 30-day, 12-month and overall mortalities than those with a SYNTAX score <9 (3.7% vs. 11.3% and 20.7% vs. 34.3%; log-rank p=0.005).

CONCLUSIONS

Significant CAD, as defined using "real-world" QCA margins, did not have a significant effect upon mortality after TAVI for severe aortic stenosis. However, higher-risk SYNTAX groups, including those with a score >9, had increased mortality.

Combined rotational atherectomy and aortic balloon valvuloplasty as a bridge to transcatheter aortic valve replacement

Patients with obstructive coronary artery disease and severe aortic stenosis have traditionally been managed with open heart surgery. In the era of transcatheter aortic valve replacement (TAVR) and high-risk coronary interventions many of those patients who were previously considered "terminal" can now be successfully managed with percutaneous coronary intervention (PCI) and TAVR. Although simple PCI can be safely combined with TAVR in the same procedure, high-risk coronary interventions often need to be performed separately. We report the first case of combined rotational atherectomy with balloon aortic valvuloplasty as a bridge to TAVR in a frail patient with complex coronary artery disease and critical aortic stenosis.

Coronary artery disease in patients undergoing TAVI: why, what, when and how to treat

Coronary artery disease (CAD) and aortic valve stenosis (AS) are frequently coexisting. It has been reported that CAD is present in 40% of patients with AS undergoing surgical aortic valve replacement, and in up to 60% of patients with AS undergoing transcatheter aortic valve implantation (TAVI). Elderly patients with CAD and AS are characterised by higher baseline risk profiles as compared to patients with isolated AS, increasing the complexity of their therapeutic management. In patients with CAD and AS the combination of coronary artery bypass grafting (CABG) and surgical aortic valve replacement has been shown to improve survival. Therefore, CABG is recommended in patients with CAD and AS undergoing surgical aortic valve replacement according to current guidelines of the European Society of Cardiology (ESC) and of the American College of Cardiology Foundation/American Heart Association (ACCF/AHA). Conversely, whether the presence of CAD has any prognostic implications in elderly patients with severe AS undergoing TAVI is still a matter of debate. Of note, according to the most recent ESC guidelines on myocardial revascularisation, percutaneous revascularisation should be considered in patients undergoing TAVI with a stenosis >70% in proximal coronary segments (class IIa, level of evidence C). The aim of this article is to provide an overview of evidence supporting the need for coronary revascularisation in patients with severe AS and CAD undergoing TAVI, and to summarise optimal timing and treatment modalities for percutaneous coronary interventions in these patients.

The prognostic impact of concomitant coronary artery bypass grafting during aortic valve surgery: implications for revascularization in the transcatheter era

OBJECTIVE

Clinicians may give greater consideration to medical management versus coronary artery bypass grafting (CABG) for coronary artery disease (CAD) at the time of aortic valve intervention. We evaluated the prognostic impact of revascularization strategy during aortic valve replacement (AVR).

METHODS

We studied 1308 consecutive patients with significant CAD (≥50% stenosis) undergoing AVR with or with out CABG between 2001 and 2010. Late mortality and its determinants were analyzed using multivariable Cox models.

RESULTS

Patients undergoing CABG (n = 1043; 18%) had more frequent angina (50% vs 26%; P < .001), left ventricular dysfunction (22% vs 14%; P = .003), advanced (>70% stenosis) CAD (85% vs 48%; P < .001), and incidence of triple-vessel/left-main CAD (44% vs 8%; P < .001). Whereas operative mortality was comparable between patients undergoing AVR plus CABG versus isolated AVR (2.9% vs 3.0%; P = .90), 5-year (72% vs 64%) and 8-year (50% vs 39%) survival was higher following CABG (P = .007). Adjusting for older age (hazard ratio [HR], 1.28 per 5 years), female sex (HR, 1.23), peripheral vascular disease (HR, 1.71), New York Heart Association functional class III to IV (HR, 1.48), and diabetes (HR, 1.50) concomitant CABG at AVR reduced late mortality risk by more than one-third (HR, 0.62, 95% confidence interval, 0.49-0.79; P < .001). CABG continued to confer a survival advantage in patients with moderate (50%-70%) (HR, 0.62; P = .02) and severe (>70%) CAD (HR, 0.62; P = .002).

CONCLUSIONS

In patients undergoing AVR with coexistent CAD, concomitant CABG reduces risk of late death by more than one-third, without augmenting operative mortality. This survival advantage persists in moderate (50% to 70%) and severe (>70%) CAD. These findings underline the prognostic importance of revascularization in this population and should influence decisions regarding revascularization strategy in patients undergoing transcatheter valve therapy.

Severe aortic stenosis and coronary artery disease

Coronary artery disease (CAD) and aortic stenosis (AS) share pathophysiological mechanisms and risk factors. Moreover, the prevalence of CAD increases among elderly patients with severe AS since disease progression is strongly associated with age for both CAD and AS. These factors contribute to the frequent coexistence of CAD and AS. Patients with concomitant AS and CAD are characterised by higher baseline risk profiles with a larger number of comorbidities as compared to patients with isolated AS. Therefore, adequate therapeutic strategies are crucial for the treatment of these patients. The number of patients undergoing concomitant coronary artery bypass grafting (CABG) and surgical aortic valve replacement (SAVR) doubled during the last decade. Moreover, the development and rapid integration of transcatheter aortic valve implantation (TAVI) into clinical practice in western European countries has further extended invasive treatment of AS to elderly high-risk patients not considered suitable candidates for SAVR, frequently presenting with CAD. The aim of this review article is to provide an overview on CAD prevalence, impact on clinical outcomes, and treatment strategies in patients with severe AS requiring SAVR or TAVI.

Complete revascularization is not a prerequisite for success in current transcatheter aortic valve implantation practice

OBJECTIVES

This study sought to assess in patients undergoing transcatheter aortic valve implantation (TAVI), the prevalence and impact of incomplete coronary revascularization defined as >50% coronary artery or graft diameter stenosis on visual assessment of the coronary angiogram.

BACKGROUND

TAVI is an established treatment option in elderly patients with aortic stenosis (AS) and a (very) high operative risk. Coronary artery disease (CAD) is often associated with AS.

METHODS

A single-center cohort of consecutive patients undergoing TAVI between November 2005 and June 2012 was evaluated for the presence of significant CAD. The decision to revascularize and pursue complete revascularization was made by heart team consensus.

RESULTS

A total of 263 consecutive patients with a mean age of 80 ± 7 years and 51% male underwent TAVI with a median follow-up duration of 16 months (interquartile range: 4.2 to 28.1 months). Significant CAD with myocardium at risk was present in 124 patients (47%), 44 of whom had had previous coronary artery bypass grafting (CABG), and the median SYNTAX score in the 81 patients without previous CABG was 9.00 (2.38 to 15.63). Staged percutaneous coronary intervention (PCI) was planned in 19 (15%) and concomitant PCI with TAVI in 20 (16%). The median post-procedural residual SYNTAX score of patients without prior CABG was 5.00 (0.13 to 9.88). Overall, 99 patients (37%) (61 with no CABG and 38 CABG patients) had incomplete revascularization after TAVI. Revascularization status did not affect clinical endpoints. Kaplan-Meier survival curves for patients with and without complete revascularization demonstrated a 1-year mortality of 79.9% versus 77.4% (p = 0.85), respectively.

CONCLUSIONS

In an elderly patient population undergoing TAVI for severe AS, a judicious revascularization strategy selection by a dedicated heart team can generate favorable mid-term outcome obviating the need for complete coronary revascularization.

Changing strategy for aortic stenosis with coronary artery disease by transcatheter aortic valve implantation

Coronary artery disease (CAD) is combined with aortic stenosis (AS) in 40-50 % of patients with typical angina. Recently, transcatheter aortic valve implantation (TAVI) has changed the guideline for AS in patients with high comorbidity. At the same time more than 60 % of isolated CABG has been performed without cardiopulmonary bypass in Japan. CABG is recommended and should be considered in patients with primary indication for AVR and luminal stenosis >70 % in major coronary arteries and the left internal thoracic artery (LITA) by guidelines. AVR is indicated for severe AS undergoing CABG. It is generally accepted to perform AVR for moderate AS at the time of CABG by valve guidelines. However, prophylactic AVR for moderate AS associated with CABG may increase the early operative risk and expose the patients to postoperative long-term valve related complications. AVR after previous CABG poses potential risk for mortality and morbidity. The presence of patent ITA is a significant risk of its injury and difficulty of myocardial protection during aortic cross-clamping. Therefore, at present, for severe AS previous CABG with patent ITA should be one of the definite indications of TAVI. Rationale of TAVI in patients with severe AS and CAD has not been clearly delineated. The safety of TAVI irrespective of the extent and anatomy of CAD is still controversial. PCI is not appropriate before TAVI in high-risk patients with CAD. In the near future hybrid TAVI will be realistic considering least operative mortality and morbidity in high-risk patients.

Adding coronary artery bypass grafting to aortic valve replacement increases operative mortality for elderly (70 years and older) patients with aortic stenosis

OBJECTIVE

This retrospective study aimed to determine the effect of simultaneous aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) on operative outcomes and long-term survival in elderly patients with a high prevalence of comorbidity.

METHODS

One hundred and fifty-seven elderly patients (70 years old or older) undergoing isolated AVR (n = 120) or combined AVR/CABG (n = 37) were evaluated. Operative outcomes were compared between the two surgical groups. Long-term survival was also compared between the groups using the Kaplan-Meier method and long-rank (Mantel-Cox) test.

RESULTS

Operative mortality was 0.8 % for the isolated AVR group and 5.4 % for the combined AVR/CABG group (p = 0.076). The length of the intensive care unit stay for the combined AVR/CABG group was significantly longer than that for the isolated AVR group (median: 40 vs. 21 h, p = 0.008). However, the occurrence rate of hospital complications, such as reoperation for bleeding, deep sternal infection, supra-ventricular arrhythmia, and neurological complications, was similar between the two groups. Actuarial survival at 3 and 5 years was 82.3 and 80.9 % for the isolated AVR group, and 88.3 and 73.0 % for the combined AVR/CABG group, respectively (p = 0.637).

CONCLUSIONS

The satisfactory operative and long-term results in our study support a more aggressive simultaneous coronary revascularization combined with AVR for aortic valve stenosis in elderly patients.