Systematic review of percutaneous coronary intervention and transcatheter aortic valve implantation for concomitant aortic stenosis and coronary artery disease

Virk, Sohaib; Tian, David H.; Liou, Kevin; Pathan, Faraz; Villanueva, Claudia; Akhunji, Zakir; Cao, Christopher

doi:10.1016/j.ijcard.2015.03.391

Cited by 19 publications

(11 citation statements)

References 16 publications

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“…Degenerative aortic stenosis (AS) is the most common valvular heart disease in both western and developed countries, affecting mainly individuals older than 60 years (1)(2)(3)(4). Co-existing coronary artery disease (CAD) is present in more than 50% of patients with severe AS over 70 years of age and in more than 65% of patients with severe AS over 80 years of age (2,3,5).…”

Section: Introductionmentioning

confidence: 99%

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

Aleksandric¹,

Banović²,

Beleslin³

2022

Front. Cardiovasc. Med.

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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.

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Section: Introductionmentioning

confidence: 99%

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

Aleksandric¹,

Banović²,

Beleslin³

2022

Front. Cardiovasc. Med.

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“…According to a recent systematic review, with a pooled incidence of 16.3%, the risk of major bleeding may be higher in patients undergoing pre-TAVI PCI owing to the necessity of dual anti-platelet therapy. [ 7 ] Another study reported that as many as 37% patients received a blood transfusion in severe symptomatic AS who underwent TAVI through the transfemoral route. [ 24 ] Therefore, we speculate that the benefit achieved by reducing contrast agent maybe offset by rising incidence of major bleeding in staged PCI and TAVR strategy.…”

Section: Discussionmentioning

confidence: 99%

“…[ 6 ] Traditionally, SAVR combined with coronary artery bypass graft surgery (CABG) has been the standard treatment option for such patients. [ 7 ] In current practice, pre-existing severe and proximal coronary artery lesions are usually treated by staged PCI before TAVR or concomitant PCI during the TAVR procedure. PCI after TAVR is relatively rare because the prosthetic valve's commissures or stent frame may be positioned in close proximity to coronary ostia and might interfere with diagnostic or guiding catheters.…”

Section: Introductionmentioning

confidence: 99%

The safety of concomitant transcatheter aortic valve replacement and percutaneous coronary intervention

Yang

Huang

et al. 2017

Medicine

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Background:TAVR is a rapidly spreading treatment option for severe aortic valve stenosis. Significant coronary artery disease (CAD) is present in 40% to 75% of patients undergoing TAVR. However, when to treat the concomitant coronary artery lesions is controversial.Methods:This is a systematic review comparing concomitant PCI and TAVR versus staged PCI and TAVR. The OVID database was systematically searched for studies reporting PCI in patients undergoing TAVR. A random effects model was used to calculate the pooled odds ratio (OR) with 95% confidence intervals.Results:Four observational studies and a total of 209 patients were included in this analysis. Overall 30-day mortality was similar between concomitant PCI and TAVR versus staged PCI and TAVR [OR: 1.47 (0.47–4.62); P = .51], renal failure was not significantly different between both groups [OR: 3.22 (0.61–17.12); P = .17], periprocedural myocardial infarction was not different between the 2 groups [OR: 1.44 (0.12–16.94); P = .77], life-threatening bleeding did not differ between both groups [OR: 0.45 (0.11–1.87); P = .27], and major stroke also was not significantly different [OR: 3.41 (0.16–74.2); P = .44].Conclusion:These data did not show a significant difference in short-term outcomes between concomitant PCI and TAVR versus staged PCI and TAVR.

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“…Large registry data have confirmed the safety of PCI (including LM disease) in the setting of severe AS, but does not address patients with severe LV dysfunction. [3][4][5]11,12 In a study by Goel et al, patients with severe symptomatic AS who had LVEF <30% had a much higher post-PCI mortality than patients with preserved LVEF (hazard ratio 2.83, confidence interval 1.79-4.49, p < 0.001). 3 As illustrated in this case, our patient would probably not have survived without mechanical circulatory support (Figure 3).…”

Section: Introductionmentioning

confidence: 99%

Mechanical circulatory support in patients with severe aortic stenosis and left ventricular dysfunction undergoing percutaneous coronary intervention

Alkhouli

Mustafa²,

Chaker³

et al. 2017

J Card Surg

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Management of obstructive coronary artery disease in patients with aortic stenosis and severe left ventricular dysfunction is challenging. Mechanical circulatory support at the time of percutaneous coronary interventions may be necessary in these extreme-risk patients. We present a case in which the TandemHeart was used to support a patient with severe aortic stenosis, severe protected left main and circumflex disease, and severe cardiomyopathy and review the literature on this subject.

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Systematic review of percutaneous coronary intervention and transcatheter aortic valve implantation for concomitant aortic stenosis and coronary artery disease

Cited by 19 publications

References 16 publications

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

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

The safety of concomitant transcatheter aortic valve replacement and percutaneous coronary intervention

Mechanical circulatory support in patients with severe aortic stenosis and left ventricular dysfunction undergoing percutaneous coronary intervention

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