Influence of coronary artery disease and percutaneous coronary intervention on mid‐term outcomes in patients with aortic valve stenosis treated with transcatheter aortic valve implantation

BackgroundA high frequency of coronary artery disease (CAD) is reported in patients with severe aortic valve stenosis (AS) who undergo transcatheter aortic valve implantation (TAVI). However, the optimal management of CAD in these patients remains unknown.HypothesisWe hypothesis that AS patients with TAVI complicated by CAD have poor prognosis. His study evaluates the prognoses of patients with CAD and severe AS after TAVI.MethodsWe divided 186 patients with severe AS undergoing TAVI into three groups: those with CAD involving the left main coronary (LM) or proximal left anterior descending artery (LAD) lesion (the CAD[LADp] group), those with CAD not involving the LM or a LAD proximal lesion (the CAD[non‐LADp] group), and those without CAD (Non‐CAD group). Clinical outcomes were compared among the three groups.ResultsThe CAD[LADp] group showed a higher incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) and all‐cause mortality than the other two groups (log‐rank p = .001 and p = .008, respectively). Even after adjustment for STS score and percutaneous coronary intervention (PCI) before TAVI, CAD[LADp] remained associated with MACCE and all‐cause mortality. However, PCI for an LM or LAD proximal lesion pre‐TAVI did not reduce the risk of these outcomes.ConclusionsCAD with an LM or LAD proximal lesion is a strong independent predictor of mid‐term MACCEs and all‐cause mortality in patients with severe AS treated with TAVI. PCI before TAVI did not influence the outcomes.     

Coronary artery disease in patients undergoing transcatheter aortic valve implantation. A single center registry on prevalence,management and immediate clinical impact

IntroductionPrevalence of coronary artery disease (CAD) ranges from 30% to 60% of all patients with aortic valve stenosis (AVS). At present, little is known about the best management of CAD in patients undergoing trans-catheter aortic valve implantation (TAVI). Aim of this study is to investigate the prevalence, management and the immediate clinical impact of CAD in this population, with a special focus on the feasibility and safety of a physiologically-guided revascularization strategy.Methods and resultsA total of 287 consecutive patients undergoing TAVI in our center were retrospectively included in the analysis. Those presenting CAD (123, 43%) were divided in three groups, according to the therapeutic strategy adopted by the operator: optimal medical therapy group (42 out of 123, 34%), preventive-PCI for angiographically significant coronary lesions (34 out of 123, 28%) and a physiologically-guided strategy (47 out of 123, 38%). The mean Logistic EuroSCORE was 31 ± 24% in the CAD population, with a higher risk profile in medical therapy group. TAVI procedural success in the overall population was 96%. Thirty-day clinical outcome showed a higher incidence of MACEs in the optimal medical therapy and the preventive PCI group (11.9% and 5.9% respectively), with no occurrence of adverse events in the FFR-guided group.ConclusionsThe best management of CAD in TAVI is still under investigation. Despite a relatively limited sample size, our findings demonstrate the feasibility and safety of a physiologically-guided revascularization strategy. Larger trials are needed to confirm our observations and to assess the long-term clinical impact.     

Comparison of outcomes in patients having isolated transcatheter aortic valve implantation versus combined with preprocedural percutaneous coronary intervention

Coronary artery disease negatively affects the outcome of patients undergoing surgical aortic valve replacement and practice guidelines recommend revascularization at time of surgery. In patients undergoing transcatheter aortic valve implantation (TAVI), the impact of preprocedural percutaneous coronary intervention (PCI) on TAVI outcome has not been examined. We aimed in the present study to assess the feasibility and safety of performing PCI before TAVI and to evaluate procedural, 30-day, and 6-month clinical outcomes. We retrospectively analyzed 125 patients who underwent successful TAVI at a single institution and divided them into an isolated TAVI and a PCI + TAVI group. During the study period, a strategy of preprocedural PCI of all significant (>50%) lesions in major epicardial vessels was adopted. Study end points were adjudicated in accordance with the Valve Academic Research Consortium consensus on event definition. All patients were treated with the Medtronic CoreValve prosthesis (n = 55 with PCI + TAVI and n = 70 with isolated TAVI). Thirty-day mortality was 2% versus 6% for patients treated with PCI + TAVI versus isolated TAVI, respectively (p = 0.27). Neither periprocedural nor spontaneous myocardial infarction occurred in either group. Rates of 30-day stroke, major bleeding, major vascular complications, and the Valve Academic Research Consortium-defined combined safety end point (11% vs 13%, p = 0.74) did not differ between the 2 groups. Patients' symptoms significantly improved in the first month after TAVI, and extent of improvement did not differ between groups. Adverse events at 6 months were comparable. In conclusion, PCI before TAVI appears feasible and safe. Based on these early results revascularization should become an important consideration in patients with coronary artery disease undergoing TAVI.     

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Complex Coronary Artery Disease

ObjectivesThe aim of this study was to compare, in a cohort of patients with complex coronary artery disease (CAD) and severe aortic stenosis (AS), the clinical outcomes associated with transfemoral transcatheter aortic valve replacement (TAVR) (plus percutaneous coronary intervention [PCI]) versus surgical aortic valve replacement (SAVR) (plus coronary artery bypass grafting [CABG]).BackgroundPatients with complex CAD were excluded from the main randomized trials comparing TAVR with SAVR, and no data exist comparing TAVR + PCI vs SAVR + CABG in such patients.MethodsA multicenter study was conducted including consecutive patients with severe AS and complex CAD (SYNTAX [Synergy Between PCI with Taxus and Cardiac Surgery] score >22 or unprotected left main disease). A 1:1 propensity-matched analysis was performed to account for unbalanced covariates. The rates of major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, nonprocedural myocardial infarction, need for new coronary revascularization, and stroke, were evaluated.ResultsA total of 800 patients (598 undergoing SAVR + CABG and 202 undergoing transfemoral TAVR + PCI) were included, and after propensity matching, a total of 156 pairs of patients were generated. After a median follow-up period of 3 years (interquartile range: 1-6 years), there were no significant differences between groups for MACCE (HR for transfemoral TAVR vs SAVR: 1.33; 95% CI: 0.89-1.98), all-cause mortality (HR: 1.25; 95% CI: 0.81-1.94), myocardial infarction (HR: 1.16; 95% CI: 0.41-3.27), and stroke (HR: 0.42; 95% CI: 0.13-1.32), but there was a higher rate of new coronary revascularization in the TAVR + PCI group (HR: 5.38; 95% CI: 1.73-16.7).ConclusionsIn patients with severe AS and complex CAD, TAVR + PCI and SAVR + CABG were associated with similar rates of MACCE after a median follow-up period of 3 years, but TAVR + PCI recipients exhibited a higher risk for repeat coronary revascularization. Future trials are warranted.     

Mechanical circulatory support with impella to facilitate percutaneous coronary intervention for post‐TAVI bilateral coronary obstruction

One of the potential complications of transcatheter aortic valve implantation (TAVI) is coronary obstruction (CO), which can occur by displacement of heavily calcified native valve cusps against the coronary ostium. Treatment mandates immediate percutaneous coronary intervention (PCI) to restore coronary flow and improve hemodynamics and if unsuccessful, urgent implementation of circulatory support, commonly extracorporeal, with subsequent surgical revascularization. We report a case of post‐TAVI CO for which successful emergent deployment of Impella percutaneous mechanical circulatory support to restore hemodynamic stability facilitated definitive treatment with bilateral PCI. Impella support represents an expeditious, effective, and widely available therapy to complement and facilitate PCI in the treatment of CO complicating TAVI, and may diminish requirement for urgent coronary artery bypass surgery. © 2015 Wiley Periodicals, Inc.     

Impact des techniques interventionnelles dans le traitement de la valvulopathie aortique après revascularisation myocardique chirurgicale préalable

IntroductionPatients with a history of coronary artery bypass and aortic valve disease constitute a high-risk group for conventional redo surgery. The transcatheter aortic valve implantation (TAVI) may be an alternative for high-risk patients. The purpose of this study is to evaluate the impact of TAVI in the treatment of aortic valve disease after previous surgical coronary artery revascularization.Patients and methodsThis is a single-center retrospective, observational study, including 87 patients undergoing surgery for surgical heart valve replacement or TAVI from January 2007 to December 2013.ResultsThe introduction of transcatheter aortic valve implantation techniques has doubled the number of redo patients treated for aortic valve disease. From 2010 to 2013, the patients treated by conventional surgery diminished by 30%, with improved postoperative outcomes. This study allowed us to notice differences in patient's in terms of operative risk factors. For the same reasons no comparison was possible between 2 subgroup of patients. Hospital mortality was 6.4% for conventional aortic surgery and 20% for transcatheter aortic valve treatment.ConclusionSurgery remains the standard treatment for aortic valve disease even in redo patients, but TAVI becomes a very interesting tool as it may represent a tailored approach for our patients.     

Aortic stenosis,angina pectoris,coronary artery disease

The data from 88 patients (pts) with aortic stenosis (AS) were reviewed to determine relationships between angina pectoris (AP) and coronary artery disease (CAD). Results of surgery performed in 81 of these pts was analyzed. All pts had coronary arterlograms, and lesions ≥ 50% were considered significant. Fifty-nine pts had an aortic valve gradient measured at catheterization ≥ 40 mmHg, and in 29 pts, AS was confirmed at operation. Sixty-eight pts (77%) experienced AP, and 32 had coexisting CAD (47%); 9 of 20 pts without AP had CAD (45%). There were no significant differences in the incidence of AP in pts divided into subgroups by the aortic valve gradient (40–50, 51–100, 101–200 mmHg) or age (40–59, 60–81 years. Also, no significant differences were found in the incidence or extent of CAD between the two age groups; the extent of CAD was similar regardless of the presence or absence of AP. In pts with AP (1) CAD was more likely in pts ≥ 60 years of age; (2) CAD was less likely when the aortic valve gradient was > 100 mmHg, suggesting that AP in these pts was due to hemodynamically severe AS. All pts with 3-vessel CAD experienced AP, and the aortic valve gradient was less in these pts than in those with no CAD or less extensive CAD. In 19 pts with combined AS and CAD who had both the aortic valve replaced and a revascularization operation only 1 of pts died in the hospital, while 3 of 19 pts with combined AS and CAD who had aortic valve replacement alone died. In this study a significant number of pts with AS experienced AP, and the presence or absence of AP did not predict coexisting CAD. Coronary arteriography is recommended in the evaluation of pts ≥ 40 years of age with AS. The operative mortality appears to be decreased in pts with AS and CAD who have combined surgery.     

Utility of Routine Invasive Coronary Angiography Prior to Transcatheter Aortic Valve Replacement

Background/purposeDespite the high prevalence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS), the optimal management of concomitant CAD, including revascularization before transcatheter aortic valve replacement (TAVR), remains controversial. Contemporary, real-world practice patterns have not yet been described. We aimed to characterize the burden of CAD in contemporary TAVR patients and evaluate revascularization practices at a high-volume center.Methods/materialsWe retrospectively analyzed all adult patients referred for TAVR at our center between January 2019 and January 2020. Presence of significant CAD and subsequent management were recorded. Presenting symptoms, use of non-invasive and invasive ischemia testing, and pre-TAVR computed tomography (CT) imaging were analyzed.ResultsA total of 394 patients with severe AS were referred for TAVR. Thirty-nine patients (9.9%) instead underwent surgery, of whom only 5 (1.3%) received coronary artery bypass grafting. Of the remaining 355 patients, 218 patients (61.4%) had insignificant CAD. Of the 137 patients (38.6%) with significant CAD, only 30 (8.5%) underwent percutaneous coronary intervention (PCI). Of these, less than half had anginal symptoms, a third had CAD in proximal segments, and a third underwent ischemia testing before PCI. Pre-TAVR CT accurately identified significant CAD in 28/30 patients (93.3%) who underwent PCI.ConclusionsOnly 1 in 25 contemporary TAVR patients had significant CAD and angina requiring intervention, calling into question the utility of routine invasive coronary angiography before TAVR. A Heart Team approach integrating anginal symptoms, ischemia testing and possibly pre-TAVR CT is needed to guide the need, timing, and strategy of revascularization.     

Impact of coronary artery disease on outcomes after transcatheter aortic valve implantation

Background: Coronary artery disease (CAD) negatively impacts prognosis of patients undergoing surgical aortic valve replacement and revascularization is generally recommended at the time of surgery. Implications of CAD and preprocedural revascularization in the setting of transcatheter aortic valve implantation (TAVI) are not known. Method: Patients who underwent successful TAVI from January 2005 to December 2007 were retrospectively divided into five groups according to the extent of CAD assessed with the Duke Myocardial Jeopardy Score: no CAD, CAD with DMJS 0, 2, 4, and ≥6. Study endpoints included 30‐day and 1‐year survival, evolution of symptoms, left ventricular ejection fraction (LVEF), and mitral regurgitation (MR) and need of revascularization during follow‐up. Results: One hundred and thirty‐six patients were included, among which 104 (76.5%) had coexisting CAD. Thirty‐day mortality in the five study groups was respectively 6.3, 14.6, 7.1, 5.6, and 17.7% with no statistically significant difference between groups (P = 0.56). Overall survival rate at one year was 77.9% (95% CL: 70.9, 84.9) with no difference between groups (P = 0.63). Symptoms, LVEF, and MR all significantly improved in the first month after TAVI, but the extent of improvement did not differ between groups (P > 0.08). Revascularization after TAVI was uncommon. Conclusion: The presence of CAD or nonrevascularized myocardium was not associated with an increased risk of adverse events in this initial cohort. On the basis of these early results, complete revascularization may not constitute a prerequisite of TAVI. This conclusion will require re‐assessment as experience accrues in patients with extensive CAD. © 2010 Wiley‐Liss, Inc.     

TAVI et revascularisation coronaire

Transcatheter aortic valve implantation (TAVI) has become the major approach to manage the severe aortic stenosis in inoperable patients that frequently present a coronary artery disease. To date, the available data related to the impact of these coronary lesions on survival is conflicting. When indicated, coronary revascularization could be beneficial for proximal lesions when performed before or during TAVI. The per-procedure coronary artery occlusion is rare, but with a bad prognosis. The coronary occlusion is more frequent with short distance of the coronary implantation and the small aortic sinuses, mostly occurring in the left main coronary. The scan analysis to identify high-risk cases is therefore important before the procedure in order to anticipate and prevent complications by specific techniques. Recently, late occlusion cases have been described and linked to thrombus or fibrosis mechanisms. The rate of success of percutaneous coronary intervention (PCI) after TAVI approach is weak, because of the difficulties of selective catheterization due to the stent of prosthesis. The different techniques of PCI have been outlined according to the type of the prosthesis.     

Safety of percutaneous coronary intervention alone in symptomatic patients with moderate and severe valvular aortic stenosis and coexisting coronary artery disease: analysis of results in 56 patients

Whether percutaneous coronary intervention (PCI) alone is safe in patients with moderate or severe aortic stenosis (AS) and coexisting coronary artery disease (CAD), and whether aortic valve replacement (AVR) can be deferred in patients with moderate AS by undergoing PCI alone is not known. We conducted a retrospective study of surgically inoperable patients with AS who underwent PCI (moderate AS, n = 28; and severe AS, n = 28) and compared to those with AVR (n = 55). The clinical characteristics, procedural complications, in-hospital and long-term clinical outcomes of PCI were compared. Baseline and procedural characteristics were similar except that lower age, hypertension, and renal impairment were seen in the AVR group. In-hospital complications were comparable among the 3 groups. Six-month and 1-year rates of myocardial infarction (MI), non-Q-wave MI, death and out-of-hospital death were similar between AVR and moderate AS patients (p = NS) and significantly high (p < 0.04) in patients with severe AS. On multivariate analysis, severe AS was the only significant predictor of 6-month and 1-year mortality. Our study suggests that PCI is safe in patients with moderate AS and coexisting CAD but is associated with poor outcomes in patients with severe AS.     

Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis

Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist, with up to two thirds of patients with AS having significant CAD. Given the challenges when both disease states are present, these patients require a tailored approach diagnostically and therapeutically. In this review the authors address the impact of AS and aortic valve replacement (AVR) on coronary hemodynamic status and discuss the assessment of CAD and the role of revascularization in patients with concomitant AS and CAD. Remodeling in AS increases the susceptibility of myocardial ischemia, which can be compounded by concomitant CAD. AVR can improve coronary hemodynamic status and reduce ischemia. Assessment of the significance of coexisting CAD can be done using noninvasive and invasive metrics. Revascularization in patients undergoing AVR can benefit certain patients in whom CAD is either prognostically or symptomatically important. Identifying this cohort of patients is challenging and as yet incomplete. Patients with dual pathology present a diagnostic and therapeutic challenge; both AS and CAD affect coronary hemodynamic status, they provoke similar symptoms, and their respective treatments can have an impact on both diseases. Decisions regarding coronary revascularization should be based on understanding this complex relationship, using appropriate coronary assessment and consensus within a multidisciplinary team.     

Impacto clínico de la extensión del miocardio en riesgo en pacientes sometidos a intervención percutánea de la válvula aórtica

Introduction and objectivesCoronary artery disease (CAD) is found in 30%-50% of patients with severe aortic stenosis (AS) undergoing treatment. The best management of CAD in AS patients undergoing transcatheter aortic valve implantation (TAVI) is still unclear. We investigated the clinical impact of the extent of jeopardized myocardium in patients with concomitant CAD and severe AS treated by TAVI.MethodsConsecutive patients who underwent TAVI procedures at our hospital were identified. In the presence of CAD, the myocardium jeopardized before TAVI was graded using the British Cardiovascular Intervention Society (BCIS) jeopardy score (JS). The study population was divided in 3 groups: patients without concomitant CAD (no-CAD), patients with CAD and BCIS-JS ≤ 4 (CAD BCIS-JS ≤ 4) and patients with concomitant CAD and BCIS-JS > 4 (CAD BCIS-JS > 4). The primary study endpoint was major adverse cardiovascular and cerebrovascular events (MACCE).ResultsA total of 403 patients entered the study: 223 no-CAD, 94 CAD BCIS-JS ≤ 4 and 86 CAD BCIS-JS > 4. At > 3 months of follow-up [range 104–3296 days], patients without CAD and CAD patients with BCIS-JS ≤ 4 had better survival free from MACCE compared with those with less extensive revascularization (BCIS-JS > 4) (P = .049). This result was driven by a significant reduction in death (P = .031). On multivariate analysis, residual BCIS-JS ≤ 4 and NYHA class III-IV independently predicted MACCE.ConclusionsIn patients with concomitant CAD and severe AS, the extent of jeopardized myocardium before TAVI impacts on clinical outcomes.     

Percutaneous Coronary Intervention of Complex Calcific Coronary Lesions Utilizing Orbital Atherectomy Prior to Transcatheter Aortic Valve Replacement

BackgroundCoronary artery disease (CAD), often with severe calcification, is present in up to 75% of patients with severe aortic stenosis (AS) referred for transcatheter aortic valve replacement (TAVR). Management of CAD in such patients is challenging. Orbital atherectomy (OA) is an effective treatment of severely calcified coronary lesions prior to stent implantation. However, there is limited data on the use of OA for percutaneous coronary intervention (PCI) to treat calcific CAD patients prior to TAVR (OA PCI + TAVR).MethodsRetrospective analysis of patients with moderate/severe calcific CAD and moderate/severe AS who underwent staged OA PCI + TAVR at one high-volume institution. Data were analyzed to assess the 1-year major adverse cardiac events after index OA PCI [MACE: death, target lesion revascularization (TLR), and myocardial infarction (MI)].ResultsThere were 18 patients (mean age of 82) treated with staged OA PCI + TAVR, and of those, 10 (56%) were male, 7 (39%) Caucasian, and 11 (61%) Hispanic/Latino. The average left ventricular ejection fraction was 49% and congestive heart failure was present in 12 patients (67%). There were no angiographic complications (0%), stent thrombosis (0%), or stroke events (0%). The 30-day and 1-year MACE rates were 5.6% (0% death, 0% TLR, 5.6% MI) and 17% (0% death, 11% TLR, and 17% MI [all non-Q-wave MI]), respectively.ConclusionsIn this single-center observational cohort series, patients with heavily calcified coronary lesions treated with OA prior to TAVR had low rates of MACE at 30 days and 1 year. The results demonstrate the feasibility and safety of OA for the treatment of complex calcific coronary lesions prior to TAVR. An up-to-date literature review of atherectomy before, during, or after TAVR in patients with concomitant severe AS and calcific CAD is also provided.Table of contents summaryThere is limited data on the use of orbital atherectomy (OA) for percutaneous coronary intervention (PCI) to treat calcific coronary artery disease (CAD) patients prior to transcatheter aortic valve replacement (TAVR). Our primary aim was to evaluate the feasibility, safety, and 1-year outcome of OA PCI pre-TAVR in patients with complex CAD and severe aortic stenosis (AS). We also aimed to provide a brief up-to-date literature review of atherectomy before, during, or after TAVR in patients with concomitant severe AS and calcific CAD. This retrospective cohort study found that OA is feasible and safe for the treatment of severely calcified coronary lesions before TAVR, resulting in acceptable 30-day and 1-year outcomes.     

Ad-hoc percutaneous coronary intervention and transcatheter aortic valve implantation as a combined transfemoral procedure

Coronary artery disease has been reported in more than 50% of patients with severe aortic stenosis above the age of 70 years. Combined surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) is associated with a higher operative risk. Concomitant coronary artery disease also increases the procedural risk of transcatheter aortic valve implantation (TAVI), and hence, a combined strategy for treating both entities needs to be carefully considered. Data regarding TAVI and percutaneous coronary intervention (PCI) as a combined percutaneous procedure are scarce. We report the case of an 84-year-old woman who presented with non-ST segment elevation myocardial infarction and impending pulmonary edema who was diagnosed with severe aortic stenosis and two-vessel coronary artery disease. Because of an elevated logistic Euroscore of 25% and her unstable presentation, percutaneous coronary revascularization and TAVI were successfully performed in a combined percutaneous transfemoral procedure. She had a smooth recovery and rehabilitation period with significant improvement in her symptoms and functional capacity. Thirty-day follow-up, including transthoracic echocardiography and cardiac magnetic resonance imaging, showed a well-functioning prosthetic valve and no signs of residual myocardial ischemia. We therefore conclude that combined PCI and TAVI is feasible and can be associated with good clinical outcomes in selected cases. Further data and experience are needed to evaluate this strategy.     

Incomplete Functional Revascularization Is Associated With Adverse Clinical Outcomes After Transcatheter Aortic Valve Implantation

Background and purposeWhether incomplete functional revascularization has an impact on the clinical outcome of patients treated with transcatheter aortic valve implantation (TAVI) is still unknown. We aim to assess the prognostic value of residual functional SYNTAX score (rFSS) in a cohort of patients undergoing TAVI.Methods and resultsOne-hundred-twenty-four patients (229 lesions) with severe aortic stenosis and coronary artery disease (CAD) underwent fractional flow reserve (FFR)-guided revascularization. The primary endpoint of the study was the composite of cardiac death, myocardial infarction, and revascularization at the last available follow-up after TAVI. Median SYNTAX score (SS) and Functional SYNTAX score (FSS) at baseline were 7 (range 5–12) and 0 (range 0–7) respectively. After revascularization or deferral according to FFR, residual SS (rSS) and rFSS were 5 (range 0–8) and 0 (range 0–0) respectively. Angiographic incomplete revascularization (rSS > 0) was not associated with the primary endpoint (HR 1.2; 95% CI 0.4–3.9; p = 0.69), whereas functional incomplete revascularization (rFSS>0) was associated with worse event-free survival at follow up after adjusting for clinical confounders (HR 3.7; 95% CI 1.0–13.7; p = 0.04).ConclusionIncomplete functional revascularization is associated with adverse clinical outcomes after TAVI. Residual functional SYNTAX score may be regarded as a treatment goal for patients with CAD undergoing TAVI. Further studies are warranted to confirm our hypothesis.     

The value of percutaneous coronary intervention in aortic valve stenosis with coronary artery disease

Objectives

The study determines whether treatment of coronary disease by percutaneous coronary intervention (PCI) in the presence of severe aortic stenosis (AS) is feasible and defines which patients might benefit most.

Background

Severe symptomatic AS is considered a class I indication for aortic valve replacement (AVR). Many patients with AS have concomitant coronary artery disease (CAD), and the true reason for symptoms is often unclear. It is common practice to combine AVR with coronary artery bypass grafting. However, in some cases PCI alone might improve symptoms and allow surgery to be deferred.

Methods

We analyzed 38 consecutive patients who underwent PCI for CAD in the presence of significant AS between 1989 and 2004. Data included demographic factors, clinical features, angiographic, and echocardiographic information. Events during follow-up included PCI complications, improvement post-PCI, AVR, and death. Statistical analysis was used to assess the impact of PCI on outcome and survival.

Results

The mean age of the study group was 71 ± 9.3 years, and the mean aortic valve area was 0.84 ± 0.28 (0.4-1.2) cm². Reasons for choosing PCI over surgery were patients’ preference, high surgical risk, and cardiologist recommendation. Thirty-five patients (92.1%) reported symptomatic improvement after PCI, and no major PCI-related complications were recorded. Significant predictors for long-term event-free survival were good functional class (P = .006) and single-vessel coronary disease (P = .017).

Conclusion

PCI in patients with severe AS and significant CAD is safe, offers relief of symptoms in most cases, and has good long-term outcome in a subset of patients who have mild CAD and good functional class. This therapeutic approach should be considered in such patients and in those with high surgical risk.     

Outcomes of patients with low‐pressure aortic gradient undergoing transcatheter aortic valve implantation

Background: The risk/benefit balance of transcatheter aortic valve implantation (TAVI) in patients with low‐gradient aortic stenosis (LGAS) remains to be well defined. Aim of the study was to investigate the impact of LGAS in patients undergoing TAVI. Methods: Medline, Cochrane Library, and Scopus were searched for articles reporting outcome of patients with LGAS undergoing TAVI. The primary endpoint was 12‐months all‐cause mortality and the secondary endpoint was 30‐day all‐cause mortality. Using event‐rates as dependent variable, a meta‐regression was performed to test for interaction between baseline clinical features (age, gender, diabetes mellitus, coronary artery disease, left ventricular ejection fraction (LVEF) and type of implanted valve) and transaortic gradient for the primary endpoint. Results: Eight studies with a total of 12,589 patients were included. Almost one‐third of the patients presented with LGAS (27.3%: 24.4–29.2). Median LVEF was 48% in patients with LGAS and 56% in patients with high‐gradient AS. Patients with LGAS were more likely to have diabetes mellitus, previous coronary artery disease, higher mean Logistic EuroSCORE, and lower EF. At 12 (12–16.6) months, low transaortic gradient emerged as independently associated with all‐cause death, both if evaluated as a dichotomous and continuous value (respectively OR 1.17; 1.11–1.23 and OR 1.02; 1–1.04, all CI 95%). Clinical variables, including EF did not affect this result. Conclusions: In a population of TAVI patients, LGAS appears to be independently related to dismal prognosis. © 2016 Wiley Periodicals, Inc.     

Stenting of the unprotected left main coronary artery in patients with severe aortic stenosis prior to percutaneous valve interventions

AimsHigh-risk patients with severe aortic stenosis (AS) who are candidates for transcatheter valve implantation (TAVI) or balloon aortic valvuloplasty (BAV) may additionally require revascularization of the unprotected left main coronary artery (UPLM). We aimed to assess the feasibility and procedural safety of UPLM stenting in such patients.Methods and ResultsTen cases of UPLM stenting prior to BAV or TAVI at three medical centers over a 2-year period were identified. Mean age was 84±4 years, aortic valve area was 0.70±0.12 cm², left ventricular ejection fraction was 58%±3%, and logistic EuroScore was 32±17. Intraaortic balloon counterpulsation was used in three patients. A single stent was used in seven patients, and two stents were used in three patients. One patient received a bare-metal stent, and the others received drug-eluting stents. No procedural complications occurred, and the patients were hemodynamically stable. Three patients subsequently underwent BAV, and seven underwent TAVI. During 6 months of follow-up, two patients died: one due to AS restenosis 6 months after BAV and one due to vascular complications 18 days after TAVI (34 days after UPLM stenting).ConclusionsStenting of the UPLM in patients with severe AS prior to percutaneous valve intervention seems feasible and safe. This approach may enable more patients to achieve comprehensive percutaneous therapy for severe coronary and valvular disease.     

Resultados intrahospitalarios tras tratamiento percutáneo frente a quirúrgico en pacientes con estenosis aórtica y enfermedad arterial coronaria concomitante

Introduction and objectivesConcomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD.MethodsUsing discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission.ResultsMatching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P < .001) as was periprocedural stroke (0.9% vs 2.2%; P = .004), acute kidney injury (4.3% vs 16.0%, P < .001), blood transfusion (9.6% vs 21.1%, P < .001), and hospital-acquired pneumonia (0.1% vs 1.7%, P = .001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P < .001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P < .001) and SAVR/CABG (8.3 vs 6.8%, P < .001). Thirty-day cardiovascular readmission did not differ between groups.ConclusionsIn this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation.