PCI before TAVR linked to better outcomes than performing both at once
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Treating patients with percutaneous coronary intervention (PCI) up to 90 days before transcatheter aortic valve replacement (TAVR) may lead to better patient outcomes than performing both procedures during the same hospitalization, according to a new analysis published in JACC: Cardiovascular Interventions.[1]
“PCI in patients undergoing TAVR used to be standard clinical practice due to concerns regarding ischemia and hemodynamic fluctuations during TAVR, often due to rapid ventricular pacing,” wrote first author Abhijeet Dhoble, MD, an interventional cardiologist with the University of Texas Health Science Center in Houston, and colleagues. “However, currently, the sequence of interventions can be tailored to an individual patient based on local heart team decision. Prior studies had a small sample size or insufficient follow-up to assess the influence of timing of PCI in patients undergoing TAVR on cardiovascular outcomes.”
Dhoble et al. explored data from more than 51,000 patients with stable coronary artery disease (CAD) who underwent both PCI and TAVR within the same 90-day period. Data came from the Society of Thoracic Surgeons/American College of Cardiology TVT Registry. All patients were treated from 2015 to 2023 with a contemporary balloon-expandable Sapien 3 TAVR valve from Edwards Lifesciences.
While 84.7% of patients underwent PCI up to 90 days ahead of TAVR, 13.9% underwent PCI at TAVR during the same hospitalization, and 1.4% underwent PCI up to 90 days after TAVR.
“Due to the very small number of patients undergoing PCI after TAVR, we decided to focus on the other two groups for primary analysis,” the authors wrote, adding that post-TAVR PCI has “been on the decline” for several years now.
After propensity matching, several different outcomes—in-hospital mortality, 30-day mortality, cardiac death, stroke, major vascular complications, life-threatening bleeding events, dialysis and permanent pacemaker implantation—were all higher for patients who underwent concomitant PCI and TAVR compared to patients who underwent PCI in advance, though the differences were quite small in some instances. Patients being treated with concomitant PCI and TAVR were also more likely to be readmitted for cardiac or noncardiac causes at both 30 days and one year.
In addition, researchers noted, the combined rate of mortality and stroke after three years was slightly higher for patients treated with PCI and TAVR at the same time.
Dhoble and colleagues did note that patients being treated with PCI and TAVR at once tended present with worse symptoms; this may help explain the slight decrease in several patient outcomes.
In terms of echocardiographic outcomes such as paravalvular leak, on the other hand, there were no significant differences between the two treatment strategies. The same was also true when focused on quality of life based on Kansas City Cardiomyopathy Questionnaire scores.
The researchers went on to highlight some of the different reasons care teams may consider one treatment strategy over another for patients with symptomatic aortic stenosis (AS) and stable CAD.
“Staged TAVR after PCI would result in divided contrast volume, reducing the risk of contrast-induced nephropathy,” they wrote. “It can also minimize the risk of myocardial ischemia and hemodynamic instability during rapid ventricular pacing for balloon valve deployment. On the other hand, the need for uninterrupted dual antiplatelet therapy after PCI could increase the risk of bleeding complications during TAVR, particularly if an alternative access strategy is used. In addition, the risk of procedural complications during PCI can be higher in the presence of untreated severe AS. Concomitant PCI with TAVR is convenient for the patients and provides an option of immediate bail-out valve deployment for decompensation during the PCI procedure.”
More research is still needed, the group concluded, to gain a better understanding of how treatment strategy may impact long-term outcomes in patients with severe AS and stable CAD.
Click here to read the full study.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.