When patients with severe aortic stenosis (AS) and coronary artery disease (CAD) are treated with transcatheter aortic valve replacement (TAVR), should they undergo revascularization with percutaneous coronary intervention (PCI) first? A team of cardiologists asked that very question in a new study, sharing their results in the American Journal of Cardiology.[1]
“As TAVR expands to lower risk patients and is the potential preferred therapy for the majority of patients with severe AS, the optimal management of concomitant CAD will be of increasing importance,” wrote first author Wassim Mosleh, MD, an interventional cardiologist with Dartmouth-Hitchcock Medical Center in New Hampshire, and colleagues. “The potential benefits of PCI before TAVR are largely unknown.”
Mosleh et al. explored data from nearly 2,000 patients treated with transfemoral TAVR at one of two U.S. facilities from February 2012 to January 2023. All patients presented with both severe symptomatic AS and significant CAD. For each patient, interventional cardiologists and cardiothoracic surgeons worked together to determine which patients needed to undergo revascularization with PCI before TAVR and which did not. Ultimately, 445 patients underwent PCI within one year of transfemoral TAVR, and the remaining 1,364 patients did not.
Overall, the study’s primary outcome—a composite of death, myocardial infarction or cardiac arrest within 30 days—was seen in 2.8% of PCI patients and 2% of patients who did not undergo PCI. This was even true in patients presenting with hemodynamically significant left main (LM) disease or proximal left anterior descending (pLAD) disease.
In addition, a detailed comparison of the two groups that examined multiple other in-hospital, 30-day and one-year outcomes failed to identify many benefits of pre-TAVR PCI. A Kaplan-Meier survival analysis did show a “nonstatistically significant trend toward higher mortality” in the PCI group after one year, but that was the most notable difference the authors detected.
“Our results indicate that PCI within 12 months from TAVR does not mitigate adverse cardiovascular outcomes, regardless of the presence of anginal symptoms on presentation, or in patients with proximal obstructive coronary disease (LM/pLAD), which have been recommended to be intervened on by current guidelines,” the authors wrote. “Before the consideration of TAVR, the contemporary multidisciplinary heart team approach should include discourse on the longitudinal management of coinciding coronary disease as part of the lifetime management of aortic valve disease.”
The group also noted that their findings suggest there are other aspects of pre-TAVR care that may need to be reconsidered.
“Our results beg the question of whether pre-TAVR baseline coronary angiography is even necessary,” the authors wrote. “Some centers use clinical assessment when deciding whether a patient would benefit from obtaining a coronary angiogram before TAVR. This decision frequently depends on the patient's anginal symptoms and, more notably, their surgical candidacy, where, if significant CAD was discovered, could alter the global approach to treatment (e.g., transition from TAVR to combined surgical aortic valve replacement and coronary artery bypass grafting).”
Read the full study here.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.