Impact of extent of coronary artery disease and percutaneous revascularization assessed by the SYNTAX score on outcomes following transcatheter aortic valve replacement

Abstract

Objectives The aim of the study was to analyze the impact of concomitant coronary artery disease (CAD) assessed by the SYNTAX score (SS) and periprocedural percutaneous coronary intervention (PCI) on outcomes after transcatheter aortic valve replacement (TAVR). Background Due to controversial data regarding the effect of CAD on outcomes after TAVR, proper revascularization strategies remain a matter of debate. Methods 553 patients with severe aortic stenosis undergoing TAVR were included in this study. SS was calculated for each patient at baseline and after PCI. Primary outcome was one-year all-cause mortality. Results 60.2% of patients (N = 333) exhibited CAD with a mean SS of 10.8 ± 8.8. Of those, 120 patients (36.0%) received periprocedural PCI. In the treatment group, mean SS was decreased from 14.9 ± 9.1 to 6.3 ± 6.7. Patients with concomitant CAD suffered more frequently from myocardial infarction (MI) post TAVR compared to those without CAD (2.1% vs. 0.0%; P < 0.01). In the CAD cohort, MI rates were comparable between patients with and without PCI (2.2% vs. 2.5%; P = 0.71). Regarding SS, patients with a residual SS < 8 showed significant lower rates of one-year mortality (9.0% vs. 18.2%; P = 0.016) and MACCE (16.5% vs. 32.2%; P = 0.001). Besides left bundle brunch, predictors for an increased one-year mortality were a residual SS ≥ 8 in the CAD group (OR = 3.17; P = 0.011) and a EuroSCORE ≥ 4% in the entire study population (OR = 2.18; P = 0.017). Conclusion Our results suggest that a residual SS-guided revascularization strategy may improve prognosis after TAVR in patients with concomitant CAD. PCI aiming for a residual SS < 8 was associated with improved one-year clinical outcomes.

Complete transcatheter versus complete surgical treatment in patients with aortic valve stenosis and concomitant coronary artery disease: Study‐level meta‐analysis with reconstructed time‐to‐event data

“…Aortic stenosis (AS) and coronary artery disease (CAD) can be found concomitantly in up to 50% of patients with the former 1,2 and in up to 70% of patients undergoing transcatheter aortic valve implantation (TAVI) 3 . Furthermore, CAD is associated with poorer outcomes in patients undergoing either TAVI 4 or surgical aortic valve replacement (SAVR) 5 …”

Management of Myocardial Revascularization in Patients With Stable Coronary Artery Disease Undergoing Transcatheter Aortic Valve Implantation

“…[16][17][18] To date, the benefit of coronary revascularization in the setting of TAVI has been mainly investigated in small, nonrandomized studies, and results are contradictory. 5,6,8,10 The ACTIVATION study is the only randomized clinical trial that explored the benefit of PCI in patients undergoing TAVI with significant CAD. 14 The trial showed similar rates of the primary composite end point of allcause death and rehospitalization at 1 year in patients receiving PCI or not (41.5% versus 44.0%).…”

“…3,4 Nevertheless, indication for treatment of significant CAD in TAVI setting still remains a matter of debate, due to the marked inconsistency of the available evidence, which are mainly based on nonrandomized data. 2,[5][6][7][8][9][10][11][12] In fact, whether performing PCI and achieving complete revascularization in patients undergoing TAVI would offer a clinical benefit in patients with significant CAD remains unclear. 13 The randomized, noninferiority ACTIVATION trial (Percutaneous Coronary Intervention Prior to Transcatheter Aortic Valve Implantation) showed that rates of death and rehospitalization at 1 year were similar between PCI and no PCI prior to TAVI.…”

Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement

“…The European Society of Cardiology (ESC) guidelines recommend PCI for coronary artery diameter stenosis > 70% in proximal segments (Class of recommendation: IIa; Level of evidence: C) in patients undergoing TAVR with concomitant CAD, with dual antiplatelet therapy (DAPT) recommended after PCI with a duration established according to bleeding risk [2] (Table 1). Prior PCI seems to have a beneficial impact on the long-term prognosis of TAVR patients with concomitant CAD [69], as incomplete revascularization has been associated with a higher rate of mortality [79,[82][83][84]. There is a lack of robust data on the optimal strategy and timing of PCI among TAVR patients with concomitant CAD, since only one underpowered randomized trial evaluated the impact of prior PCI in this population [85].…”