Coronary Artery Disease in Patients with Aortic Stenosis and Transcatheter Aortic Valve Implantation: Implications for Management

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.

Evaluation and management of coronary artery disease in patients undergoing transcatheter aortic valve implantation

“…Given these studies and other observational and retrospective studies, it does appear that the presence of CAD is associated with worse outcomes in some subgroups of TAVI patients with complex CAD and high SYNTAX scores [14,15] , and revascularization with PCI does improve intermediate and long-term mortality. However, the benefit of PCI needs to be individualized.…”

Antithrombotic Therapy in Patients Undergoing Transcatheter Aortic Valve Implantation

“…The endothelialization process varies in time and completeness depending on the device size and type [13] and while theoretically, this may represent a concern for device thrombosis, currently there is no clear evidence that antithrombotic therapy has a true clinical impact [14]. On the other hand, it is well established that after TAVI patients are exposed to a higher and temporally variable risk of ischemic events, including transient ischemic attack (TIA), stroke, myocardial infarction (MI) [15][16][17][18][19][20][21][22][23][24] and valve thrombosis [25,26]. Hence, evaluating the impact of different antithrombotic strategies to mitigate this risk has been the core focus of multiple clinical studies.…”

Coronary artery disease and transcatheter aortic valve implantation: diagnostic evaluation, management and indication for percutaneous revascularization

“…To date, TAVI is recommended in older patients (>75 years), or in those who are high risk (STS-PROM/EuroSCORE II >8%) (3). Several studies have demonstrated the association between AS and coronary artery disease (CAD), which increases with the age, as the risk factors for aortic stenosis are similar to those for atherosclerotic disease (4). Specifically, CAD has been reported in ≥50% of AS patients undergoing both SAVR and TAVI (5).…”