1
|
Zhang X, Geng W, Yan S, Zhang K, Liu Q, Li M. Comparison of the outcomes of concurrent versus staged TAVR combined with PCI in patients with severe aortic stenosis and coronary artery disease: a systematic review and meta-analysis. Coron Artery Dis 2024:00019501-990000000-00222. [PMID: 38682469 DOI: 10.1097/mca.0000000000001373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
BACKGROUND The optimal timing for percutaneous coronary intervention (PCI) in patients undergoing transcatheter aortic valve replacement (TAVR) remains uncertain. This research aims to evaluate the results of patients diagnosed with severe aortic valve stenosis and coronary artery disease who undergo either simultaneous or staged PCI therapy during TAVR procedures. METHODS We retrieved all relevant studies from our self-constructed databases up to January 2, 2024, encompassing databases such as Embase, Medline, Cochrane Library, and PubMed. RESULTS A total of nine studies were included, and the results showed that both surgical modalities had good safety profiles in the early and long-term stages. For early endpoint events, the risk of all-cause mortality and major bleeding within 30 years was similar in the staged TAVR + PCI and the contemporaneous TAVR + PCI (P > 0.05). Additionally, the risk of myocardial infarction, stroke, acute kidney injury and pacemaker implantation within 30 days or perioperatively is similar (P > 0.05). For long-term endpoint events, the risk of all-cause mortality, myocardial infarction and stroke was similar in the two groups at ≥2 years (P > 0.05). CONCLUSION In patients undergoing TAVR who required coronary revascularization, no significant differences were observed in the early and long-term outcomes between those receiving concurrent TAVR and PCI versus staged surgery.
Collapse
Affiliation(s)
- Xiangyu Zhang
- Department of Cardiology, Baoding First Central Hospital, Baoding City, China
| | | | | | | | | | | |
Collapse
|
2
|
Belur AD, Solankhi N, Sharma R. Management of coronary artery disease in patients with aortic stenosis in the era of transcatheter aortic valve replacement. Front Cardiovasc Med 2023; 10:1139360. [PMID: 37408653 PMCID: PMC10318168 DOI: 10.3389/fcvm.2023.1139360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Agastya D. Belur
- Cardiovascular Disease Fellowship Program, University of Louisville School of Medicine, Louisville, KY, United States
| | - Naresh Solankhi
- Jewish Hospital Cardiology, University of Louisville Jewish Hospital, Louisville, KY, United States
| | - Ravi Sharma
- Jewish Hospital Cardiology, University of Louisville Jewish Hospital, Louisville, KY, United States
| |
Collapse
|
3
|
Machanahalli Balakrishna A, Ismayl M, Palicherla A, Aboeata A, Goldsweig AM, Zhao DX, Vallabhajosyula S. Impact of prior coronary artery bypass grafting on periprocedural and short-term outcomes of patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis. Coron Artery Dis 2023; 34:42-51. [PMID: 36326179 DOI: 10.1097/mca.0000000000001200] [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] [Indexed: 11/06/2022]
Abstract
BACKGROUND The effect of prior coronary artery bypass graft (CABG) on the outcomes of transcatheter aortic valve replacement (TAVR) remains incompletely characterized. In this meta-analysis, we investigated the impact of prior CABG on TAVR outcomes. METHODS A systematic search was conducted in PubMed, Google Scholar, and Cochrane databases from inception to 24 July 2022, using the search terms 'TAVR', 'CABG', 'peri-procedural complications', and 'mortality'. The major outcomes were peri-procedural complications, intraprocedural mortality, 30-day mortality, and 30-day cardiac mortality. We used random-effects models to aggregate data and to calculate pooled incidence and risk ratios with 95% confidence intervals (CIs). RESULTS Among 116 results from the systematic search, a total of 8 studies (5952 patients) were included. Compared to patients without previous CABG, patients with prior CABG undergoing TAVR were younger, predominantly male sex, had more comorbidities, higher rates of peri-procedural myocardial infarction (MI) [relative risk (RR) 1.93; 95% CI, 1.09-3.43; P = 0.03], but lower rates of stroke (RR 0.71; 95% CI, 0.51-0.99; P = 0.04), major vascular complications (RR 0.70; 95% CI, 0.51-0.95; P = 0.02), and major bleeding (RR 0.70; 95% CI, 0.56-0.88; P = 0.002). There were no significant differences between the two cohorts in rates of pacemaker implantation, cardiac tamponade, acute kidney injury, intra-procedural mortality, 30-day mortality, and 30-day cardiac mortality. CONCLUSION Among patients undergoing TAVR, a history of prior CABG was not associated with an increased risk of periprocedural complications (except for acute MI) or short-term mortality compared to those without CABG.
Collapse
Affiliation(s)
| | - Mahmoud Ismayl
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Anirudh Palicherla
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Ahmed Aboeata
- Division of Cardiovascular Medicine, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - David X Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
4
|
de Azevedo Filho AF, Accorsi TA, Ribeiro HB. Coronary Artery Disease in Patients with Aortic Stenosis and Transcatheter Aortic Valve Implantation: Implications for Management. Eur Cardiol 2021; 16:e49. [PMID: 34950245 PMCID: PMC8674631 DOI: 10.15420/ecr.2021.27] [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: 06/11/2021] [Accepted: 08/16/2021] [Indexed: 01/09/2023] Open
Abstract
Aortic valve stenosis (AS) is the most common valvular heart disease among elderly patients. Since the pathophysiology of degenerative AS shares common pathways with atherosclerotic disease, the severity of AS in the elderly population is often concurrent to the presence of coronary artery disease (CAD). Although surgical aortic valve replacement has been the standard treatment for severe AS, the high operative morbidity and mortality in complex and fragile patients was the trigger to develop less invasive techniques. Transcatheter aortic valve implantation (TAVI) has been posed as the standard of care for elderly patients with severe AS with various risk profiles, which has meant that the concomitant management of CAD has become a crucial issue in such patients. Given the lack of randomised controlled trials evaluating the management of CAD in TAVI patients, most of the recommendations are based on retrospective cohort studies so that the Heart Team approach – together with an assessment of multiple parameters including symptoms and clinical characteristics, invasive and non-invasive ischaemic burden and anatomy – are crucial for the proper management of these patients. This article provides a review of current knowledge about assessment and therapeutic approaches for CAD and severe AS in patients undergoing TAVI.
Collapse
Affiliation(s)
| | - Tarso Ad Accorsi
- Department of Valvular Heart Disease, Heart Institute (InCor), University of São Paulo São Paulo, Brazil.,Samaritano Paulista Hospital São Paulo, Brazil
| | - Henrique B Ribeiro
- Samaritano Paulista Hospital São Paulo, Brazil.,Interventional Cardiology Department, Heart Institute (InCor), University of São Paulo São Paulo, Brazil
| |
Collapse
|
5
|
Hermiller JB, Gunnarsson CL, Ryan MP, Moore KA, Clancy SJ, Irish W. The need for future coronary access following surgical or transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2021; 98:950-956. [PMID: 34227736 DOI: 10.1002/ccd.29841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/24/2021] [Accepted: 06/11/2021] [Indexed: 11/10/2022]
Abstract
The aim of the study was to estimate the percentage of Medicare patients needing coronary access for percutaneous coronary intervention (PCI) or coronary angiography following aortic valve replacement (AVR). Indications for TAVR have expanded to include younger and low-risk patients, raising the question of coronary access for future procedures. Medicare patients <80 years old with an AVR between 2011 and 2018 were included. Time-to-event analyses were conducted using Cox hazard models to estimate risk of coronary access up to 7 years after AVR. Model adjustments included age, sex, race, region, comorbidity, concomitant CABG, and smoking. A total of 13,469 Medicare patients (mean age 70.6) met inclusion criteria. Models estimated that 2.5% of patients at 1-year post-index and 17% at over 7 years would need coronary access. For patients who had SAVR (with or without CABG), estimates for coronary access were similar and over 15% after 6.5 years. For TAVR patients, with a previous PCI, 28% at 4.5 years required coronary access, which was higher than TAVR patients without a previous PCI. SAVR patients with and without CAD at baseline were similar; however, TAVR patients with CAD had a 22% rate of coronary access versus 7% for those without at 3 years. Approximately half of patients who needed coronary access returned to the same hospital as their initial AVR. Coronary access is required in a substantial portion of AVR patients especially those with PCI or a history of CAD undergoing TAVR. The need for coronary access may increase as transcatheter AVR becomes accessible to younger patients with a longer life expectancy.
Collapse
Affiliation(s)
- James B Hermiller
- Deptartment of Cardiology, Ascension St. Vincent's Heart Center of Indiana, Indianapolis, Indiana, USA
| | | | | | | | | | - William Irish
- Department of Surgery, East Carolina University, Greenville, North Carolina, USA
| |
Collapse
|
6
|
Frattini S, Troise G, Fucci C, Pressman GS, Faggiano P. Aortic valve stenosis and cancer: a common and complex association. Expert Rev Cardiovasc Ther 2021; 19:289-299. [PMID: 33688784 DOI: 10.1080/14779072.2021.1902306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction. The prevalence of aortic valve stenosis (AS) and malignancy are both high, especially in elderly people and in developed countries. These two conditions frequently coexist and share the same risk factors as atherosclerotic disease.Area covered. The progression of calcified AS may be accelerated by both cardiovascular risk factors and cancer treatments, such as radiotherapy. The standard treatment for symptomatic severe AS is surgical aortic valve replacement; however, in cancer patients, transcatheter implantation may be preferred as they are often at high-risk for cardiac surgery. In patients with AS and cancer, physicians may face difficult treatment decisions.To date, there is limited information on the impact of malignancy on outcomes in patients with severe AS; hence, there is no established treatment policy.Expert Opinion. Treating clinicians must integrate complex information about the severity of valve disease and expected cardiac outcomes with information regarding the cancer prognosis and the need for specific treatment, including surgery. Other comorbidities, age and frailty also contribute to decision-making about whether, when, and how to perform aortic valve replacement.
Collapse
Affiliation(s)
| | - Giovanni Troise
- Cardiac Surgery Division, Fondazione Poliambulanza, Brescia, Italy
| | - Carlo Fucci
- Cardiac Surgery Division, Spedali Civili, Brescia, Italy
| | - Gregg S Pressman
- Einstein Medical Center, Heart and Vascular Institute, Philadelphia, Pennsylvania, US
| | - Pompilio Faggiano
- , University of Brescia and Fondazione Poliambulanza, Brescia, Italy
| |
Collapse
|
7
|
Manuel L, Fong LS, Bassin L. Robotic approach to the porcelain aorta: staged transcatheter aortic valve replacement and robotically assisted coronary artery bypass. ANZ J Surg 2020; 91:E128-E129. [PMID: 33107164 DOI: 10.1111/ans.16183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 06/01/2020] [Accepted: 07/05/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Lucy Manuel
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Cardiothoracic Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Laura S Fong
- Department of Cardiothoracic Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Levi Bassin
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Cardiothoracic Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
8
|
Tarus A, Tinica G, Bacusca A, Artene B, Popa IV, Burlacu A. Coronary revascularization during treatment of severe aortic stenosis: A meta-analysis of the complete percutaneous approach (PCI plus TAVR) versus the complete surgical approach (CABG plus SAVR). J Card Surg 2020; 35:2009-2016. [PMID: 32667080 DOI: 10.1111/jocs.14814] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/08/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The management of patients with coexisting severe aortic stenosis (AS) and coronary artery disease (CAD) is still facing a great deal of uncertainty when it comes to choosing between the entire surgical versus the complete percutaneous approaches, after accurately balancing risks versus outcomes. AIM To evaluate clinical outcomes and mortality of transcatheter aortic valve replacement (TAVR) plus percutaneous coronary intervention (PCI) compared with surgical aortic valve replacement (SAVR) plus coronary arteries bypass grafting (CABG) procedures in patients with concomitant AS and CAD. METHODS Electronic databases of PubMed, EMBASE, and SCOPUS were searched for relevant articles assessing outcome parameters of interest. The study endpoints were the rate of overall myocardial infarction and stroke within 30 days and the rate of 30-day mortality and 2-year mortality between patients with TAVR/PCI and those with SAVR/CABG. RESULTS Random-effect meta-analysis did not reveal any significant difference between 30-day safety outcomes: myocardial infarction (TAVR/PCI vs SAVR/CABG: odds ratio [OR]: 0.52; 95% confidence interval [CI]: 0.20-1.33; I2 = 0%), stroke (TAVR/PCI vs SAVR/CABG: OR: 0.88; 95% CI: 0.45-1.73; I2 = 0%). No significant difference in 30-day mortality (OR: 0.72; 95% CI: 0.43-1.21; I2 = 0%) and 2-year mortality (OR: 1.50; 95% CI: 0.77-2.94; I2 = 81%) rate was noted between patients with TAVR/PCI and those with SAVR/CABG. CONCLUSIONS When comparing the total percutaneous and total surgical treatment, no significant difference in short-term safety outcomes or early and late mortality was observed. More evidence is needed to guide the clinical decision.
Collapse
Affiliation(s)
- Andrei Tarus
- Department of Cardiovascular Surgery, Cardiovascular Diseases Institute, Iasi, Romania
| | - Grigore Tinica
- Department of Cardiovascular Surgery, Cardiovascular Diseases Institute, Iasi, Romania.,Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Alberto Bacusca
- Department of Cardiovascular Surgery, Cardiovascular Diseases Institute, Iasi, Romania
| | - Bogdan Artene
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
| | - Iolanda V Popa
- Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Alexandru Burlacu
- Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania.,Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
| |
Collapse
|
9
|
Degenerative Severe Aortic Stenosis and Concomitant Coronary Artery Disease: What Is Changing in the Era of the “Transcatheter Revolution”? Curr Atheroscler Rep 2020; 22:17. [PMID: 32451750 DOI: 10.1007/s11883-020-0835-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
10
|
Meta-Analysis of Transcatheter Versus Surgical Aortic Valve Replacement in Low Surgical Risk Patients. Am J Cardiol 2020; 125:1230-1238. [PMID: 32089249 DOI: 10.1016/j.amjcard.2020.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/14/2020] [Accepted: 01/17/2020] [Indexed: 01/28/2023]
Abstract
Current guidelines recommend transcatheter aortic valve implantation (TAVI) for patients with severe aortic stenosis at elevated surgical risk, but not for patients at low surgical risk. Our objective is to compare major clinical outcomes and procedural complications with TAVI versus surgical aortic valve replacement in patients with severe aortic stenosis at low surgical risk. We conducted a systematic review and meta-analysis of randomized controlled trials, identified through a systematic search of the MEDLINE, Embase, and Cochrane databases. Count data were pooled across trials using random-effects models with inverse variance weighting to obtain relative risks (RRs) and corresponding 95% confidence intervals (CIs). Three randomized controlled trials (n = 2,629) were included. At 30 days, TAVI was associated with a substantial reduction in all-cause mortality (RR: 0.45, 95%CI: 0.20 to 0.99), atrial fibrillation (RR: 0.27, 95%CI: 0.17 to 0.41), life threatening/disabling bleeding (RR: 0.29, 95%CI: 0.12 to 0.69), and acute kidney injury (RR: 0.28, 95%CI: 0.14 to 0.57). The reduction in atrial fibrillation persisted at 12 months (RR: 0.32, 95%CI: 0.21 to 0.49). However, TAVI patients had an increased risk of permanent pacemaker implantation at both 30 days (RR: 3.13, 95%CI: 1.36 to 7.21) and 12 months (RR: 2.99, 95%CI: 1.19 to 7.51). Due to the low absolute numbers of events, results were inconclusive at 30 days and 12 months for cardiovascular mortality, stroke, transient ischemic attack, and myocardial infarction. In conclusion, while some outcomes remained inconclusive, these data suggest that TAVI should be considered as a first-line therapy for the treatment of severe aortic stenosis in low surgical risk patients.
Collapse
|
11
|
Katta N, Abbott JD, Kalra A, Alenezi F, Goldsweig A, Aronow H, Velagapudi P. Management of Coronary Artery Disease in the Setting of Transcatheter Aortic Valve Replacement. Heart Int 2020; 14:24-28. [PMID: 36277671 PMCID: PMC9524713 DOI: 10.17925/hi.2020.14.1.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 03/06/2020] [Indexed: 07/21/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Natraj Katta
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Ankur Kalra
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | | |
Collapse
|
12
|
Affiliation(s)
- Sonali Kumar
- Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Michael McDaniel
- Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Habib Samady
- Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Farshad Forouzandeh
- Division of Cardiology Department of Medicine Emory University Atlanta GA.,Division of Cardiology Department of Medicine Case Western Reserve University Cleveland OH
| |
Collapse
|