Comparison of Outcomes in Patients Having Isolated Transcatheter Aortic Valve Implantation Versus Combined With Preprocedural Percutaneous Coronary Intervention

doi:10.1016/j.amjcard.2011.09.053

The American Journal of Cardiology

Volume 109, Issue 4, 15 February 2012, Pages 581-586

https://doi.org/10.1016/j.amjcard.2011.09.053 Get rights and content

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.

Section snippets

Methods

From September 2007 through March 2011, 129 consecutive patients with severe symptomatic aortic stenosis (aortic valve area <1.0 cm² or body surface area–indexed aortic valve area <0.6 cm²/m²) were treated with TAVI at our institution. Surgical aortic valve replacement (SAVR) was not performed by a cardiac surgeon based on high morbidity and mortality scores (≥80 years of age and logistic European System for Cardiac Operative Risk Evaluation score ≥20% or logistic European System for Cardiac

Results

Of 125 patients treated with TAVI, 55 patients received PCI before TAVI (PCI + TAVI group) and 70 patients were treated with isolated TAVI. Most baseline clinical characteristics were comparable between groups. Men constituted 47% of patients in the PCI + TAVI group compared to 49% in the isolated TAVI group (p = 0.89) and diabetes mellitus was prevalent in 33% versus 20% (p = 0.11). Overall, 91 patients (73%) had CAD. In the isolated TAVI group 51% of patients had a history of CAD; 33% had

Discussion

The present analysis represents the first report of short- and midterm outcomes of a systematic strategy of preprocedural PCI in patients with nonrevascularized CAD treated with TAVI. The most important finding from this analysis is that PCI before TAVI is not associated with an increased 30-day or 6-month adverse event rate. Hence, PCI before TAVI appears feasible and safe.

Although treating concomitant CAD has been shown to negatively affect the safety of SAVR,5, 6, 7 combined SAVR and

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Cited by (124)

Percutaneous coronary intervention before transcatheter aortic valve implantation: A propensity score matched analysis
2024, Cardiovascular Revascularization Medicine
The role of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD) who subsequently undergo transcatheter aortic valve replacement (TAVR) remains uncertain. Therefore, we conducted this study to assess the association of PCI before TAVR with mortality and cardiovascular outcomes.
We used the TriNetX database (Jan 2012 - Aug 2022) and grouped patients into PCI (3 months or less) before TAVR and no PCI. We performed propensity score matched (PSM) analyses for outcomes at 30 days and 1 year.
Of 17,120 patients undergoing TAVR, 2322 (14 %) had PCI, and 14,798 (86 %) did not have PCI before TAVR. In the PSM cohort (2026 patients in each group), PCI was not associated with lower all-cause mortality at 30 days (HR: 1.25, 95 % CI: 0.82–1.90) or 1 year (HR: 1.02, 95 % CI: 0.83–1.24). Frequency of repeat PCI after TAVR was low in both no PCI vs. PCI (2.4 % vs. 1.2 %) at 1 year; PCI was associated with a lower rate of repeat PCI (HR: 0.49, 95 % CI: 0.30–0.80). Sensitivity analysis revealed an E-value of 3.5 for repeat PCI (E-value for lower CI for HR: 1.81). PCI was not linked to reductions in MI, heart failure exacerbation, all-cause hospitalization, major bleeding, or permanent pacemaker/implantable cardioverter defibrillator.
This analysis showed that PCI prior to TAVR was not associated with improvement in all-cause mortality. However, PCI was associated with a reduced rate of repeat PCI at 1 year.
In-Hospital Outcomes of Combined Coronary Revascularization and Transcatheter Aortic Valve Implantation in Inpatient Nationwide Analysis
2024, Current Problems in Cardiology
Transcatheter aortic valve implantation (TAVI) is accepted as an alternative to surgery, but data on combined percutaneous coronary interventions (PCI) and TAVI during the same in-hospital stay are still lacking. Using the national inpatient sample (NIS) database, we identified all TAVI encounters and compared in-hospital outcomes of patients who had TAVI only to patients who had TAVI and PCI. We used multivariable logistic regression analysis to calculate the adjusted odds ratio (aOR). Of 291,810 patient encounters with TAVI, 13,114 (4.5%) had combined PCI during the same index admission. The average age was 79.61 ± 8.61 years in the TAVI-only vs 80.25 ± 8.73 years in the combined TAVI-PCI group. Combined TAVI and PCI was associated with higher in-hospital mortality (4.5% vs 1.8%, aOR: 2.3), stroke (4.7% vs 2.9%, aOR: 1.4), net adverse events (NAE) (20.2% vs 5.7%, aOR: 3.6), major bleeding (40.1% vs 24.3%, aOR: 1.8), vascular complications (10.6% vs 2.5%, aOR: 3.9), acute kidney injury (AKI) (23.3% vs 11.7%, aOR: 2.1), hemodialysis (HD) (4.2% vs 2.4%, aOR: 1.4), postoperative cardiogenic shock (1.2% vs 0.4%, aOR: 2.8), need for mechanical circulatory support (6.9% vs 1%, aOR: 7); p-value < 0.001 for all. The utilization of permanent pacemakers was similar between the groups (9.8% vs 9.2%, aOR: 1; p = 0.6). Combining TAVI and PCI during the same index admission is associated with worse outcomes. The decision to do PCI for patients undergoing TAVI should be individualized and tailored based on the patient's clinical conditions.
Impact of Chronic Coronary Artery Disease and Revascularization Strategy in Patients with Severe Aortic Stenosis Who Underwent Transcatheter Aortic Valve Implantation
2023, American Journal of Cardiology
The prognostic impact of coronary artery disease (CAD) after transcatheter aortic valve implantation (TAVI) is controversial. The aim of this study is to investigate the impact of CAD and different revascularization strategies on clinical outcomes in patients who underwent TAVI with third generation devices. Patients enrolled in the national observational Observational Study of Effectiveness of SAVR-TAVI Procedures for Severe Aortic Stenosis Treatment II study were stratified according to the presence of CAD (CAD+, n = 1,130) versus no CAD (CAD−, n = 1,505), and compared using a propensity matched analysis. CAD+ group was further stratified according to the revascularization strategy: no revascularization (n = 331), revascularization performed >90 days before index-TAVI (n = 417) and coronary revascularization performed <90 days before index-TAVI or during TAVI (n = 382). In-hospital, 30-day and 1-year clinical outcomes were estimated. The mean age of the overall population was 81.8 years; 54.9% of patients were female. Propensity score matching yielded 813 pairs and their 30-day all-cause mortality was comparable (p = 0.480). Major periprocedural adverse events were also similar between the groups. At 1-year follow-up, the rate of major adverse cardiac and cerebrovascular events (MACCEs) and all-cause mortality were similar between the groups (p = 0.732 and p = 0.633, respectively). Conversely, patients with CAD experienced more often myocardial infarction and need for percutaneous coronary intervention at 1 year (p = 0.007 and p = 0.001, respectively). Neither CAD nor revascularization strategy were independent predictors of 1-year MACCE. About 40% of patients presenting with severe AS and who underwent TAVI had concomitant CAD. The presence of CAD had no impact on all-cause mortality and MACCE 1-year after TAVR. However, CAD carries a higher risk for acute myocardial infarction and need of percutaneous coronary intervention during follow-up.
Clinical Outcomes of Transcatheter Aortic Valve Replacement With and Without Percutaneous Coronary Intervention—An Updated Meta-Analysis and Systematic Review
2023, Current Problems in Cardiology
Transcatheter aortic valve replacement (TAVR) is indicated for high-risk patients with severe degenerative aortic stenosis (AS). Given the shared risk factors and coexistence of obstructive coronary artery disease (CAD) and AS, there is inconsistent clinical data regarding potential survival benefits of paired percutaneous coronary intervention (PCI) with TAVR procedures. We performed a literature search using PubMed, Embase, and Cochrane Library from inception through June 2023 assessing the impact of concomitant PCI in patients with obstructive CAD undergoing TAVR. The primary outcomes were 30-day all-cause mortality, 30-day cardiovascular mortality, and 6 months-1 year all-cause mortality. Secondary outcomes included 30-day myocardial infarction, stroke, major bleeding complications, and acute kidney injury (AKI). A total of 11 studies involving 2804 patients were included in the final analysis. Compared to patients undergoing TAVR alone, the TAVR+PCI group showed no significant difference in 30-day all-cause mortality (RR 0.90, CI 0.66, 1.22, P = 0.49), 30-day cardiovascular mortality (RR 0.71 CI 0.44, 1.14, P = 0.16), or 6 months-1 year all-cause mortality (RR 0.94, CI 0.75, 1.18, P = 0.57). Regarding secondary outcomes, 30-day myocardial infarction was higher in the TAVR+PCI group (RR 3.09, CI 1.26, 7.57, P = 0.01), with no significant differences noted in rates of 30-day stroke (RR 1.14, CI 0.56, 2.33, P = 0.72), major bleeding/vascular complications (RR 1.11, CI 0.79, 1.56, P = 0.55), and AKI (RR 1.07, CI 0.75, 1.54, P = 0.71). Concomitant PCI does not confer any mortality benefit in patients with obstructive CAD and high-grade AS undergoing TAVR. Further trials are needed to confirm our findings.
Catheter versus surgical approach for the management of concomitant aortic stenosis and coronary artery disease: An inverse probability treatment weighting analysis
2023, Archives of Cardiovascular Diseases
Two therapeutic strategies are available when aortic stenosis and coronary artery disease coexist: a transcatheter approach, with percutaneous coronary intervention followed by transcatheter aortic valve replacement; and a surgical approach, consisting of surgical aortic valve replacement combined with coronary artery bypass graft.
We sought to compare the outcomes of these two strategies.
The study population consisted of 241 patients who benefited from aortic valve replacement and coronary revascularization (transcatheter, n = 150; surgery, n = 91).
Patients in the transcatheter population were older (83.5 vs. 71.8 years; P < 0.001) and had a higher Logistic EuroSCORE (11.1% vs. 5.7%; P < 0.001). At 30 days postprocedure, patients who had surgery exhibited more life-threatening bleedings (12.1% vs 4.5%; P = 0.034), acute kidney injury (12.1% vs. 1.3%; P < 0.001) and atrial fibrillation (55.6% vs. 8.7%; P < 0.001). After a median follow-up of 27 months, the risk of major adverse cardiovascular or cerebrovascular events did not differ significantly between the two strategies (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.97–2.04; P = 0.07), whereas estimated glomerular filtration rate < 60 mL/min (HR 2.22, 95% CI 1.58–3.12; P < 0.001), peripheral artery disease (HR 2.00, 95% CI 1.37–2.91; P < 0.001) and left ventricular ejection fraction < 50% (HR 1.69, 95% CI 1.12–2.55; P = 0.012) were associated with a negative prognosis.
In our study, patients with aortic stenosis and coronary artery disease treated by catheter were older and had a higher co-morbidity burden than those treated by surgery. The surgical strategy was associated with a higher rate of 30-day complications, but long-term outcomes were similar between the two strategies.
Clinical impact of the extent of jeopardized myocardium in patients undergoing transcatheter aortic valve intervention
2023, Revista Espanola de Cardiologia
La enfermedad coronaria (EC) se encuentra en el 30-50% de los pacientes con estenosis aórtica (EA) grave que reciben tratamiento intervencionista. Todavía no está claro cuál es el mejor tratamiento de la EAC en pacientes con EA sometidos a implante percutáneo de válvula aórtica (TAVI). El objetivo del estudio fue analizar el impacto clínico del miocardio en riesgo en pacientes con EAC y EA grave tratados con TAVI.
Se incluyó a pacientes consecutivos sometidos a TAVI en nuestro hospital. En presencia de EAC, el miocardio en riesgo antes del procedimiento se clasificó utilizando la puntuación de riesgo (JS) de la British Cardiovascular Intervention Society (BCIS). La población de estudio se dividió en 3 grupos: pacientes sin EAC concomitante (grupo No-EAC), pacientes con EAC y BCIS-JS ≤ 4 (grupo EAC BCIS-JS ≤ 4) y pacientes con EAC concomitante y BCIS-JS > 4 (grupo EAD BCIS -JS > 4). El objetivo primario del estudio fueron los eventos cardiovasculares y cerebrovasculares adversos mayores (MACCE).
Se incluyó a un total de 403 pacientes: 223 No-EAD, 94 EAC BCIS-JS ≤ 4 y 86 EAC BCIS-JS > 4. Con 3 meses de seguimiento [rango 104 – 3.296 días], los pacientes sin EAC y los pacientes con EAC con BCIS-JS ≤ 4 tuvieron una mejor supervivencia libre de MACCE en comparación con aquellos con revascularización menos extensa (BCIS-JS > 4) (p = 0,049). Este resultado se debió en parte a una reducción significativa de la mortalidad (p = 0,031). En el análisis multivariado, el BCIS-JS residual ≤ 4 y la clase III-IV de la NYHA predijeron MACCE de forma independiente.
En pacientes con EAC y EA grave, la extensión del miocardio en riesgo antes del TAVI influye en los resultados clínicos.
Coronary 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.
Consecutive 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).
A 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.
In patients with concomitant CAD and severe AS, the extent of jeopardized myocardium before TAVI impacts on clinical outcomes.

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: Dr. Mostafa is currently at Ain Shams University Hospital, Cairo, Egypt.

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Valvular heart diseaseComparison of Outcomes in Patients Having Isolated Transcatheter Aortic Valve Implantation Versus Combined With Preprocedural Percutaneous Coronary Intervention

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Ann Thorac Surg

J Am Coll Cardiol

Thirty-day results of the SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) Registry: a European registry of transcatheter aortic valve implantation using the Edwards SAPIEN valve

Circulation

Valvular heart disease
Comparison of Outcomes in Patients Having Isolated Transcatheter Aortic Valve Implantation Versus Combined With Preprocedural Percutaneous Coronary Intervention