Transcatheter aortic valve replacement (TAVR) patients who also present with coronary artery disease (CAD) face a much greater mortality risk, according to new findings published in JACC: Cardiovascular Interventions.[1] However, treating the patient with angiography-guided percutaneous coronary intervention (PCI) prior to TAVR is not associated with better outcomes.
“CAD has been reported in 60% to 80% of patients with severe aortic stenosis (AS) presenting for valvular intervention,” wrote first author Lennert Minten, MD, of the department of cardiovascular sciences at Katholieke Universiteit Leuven in Belgium, and colleagues. “This strong relationship may be explained by shared risk factors such as chronic kidney disease, diabetes mellitus, hypertension, hypercholesterolemia, sex, and age. When surgical aortic valve replacement is chosen, the European and American guidelines recommend simultaneous surgical revascularization of significant coronary lesions. However, the need and timing for PCI in relation to TAVR is much less clear, and no consensus exists to date, mainly owing to a lack of standardized high-quality and randomized prospective data.”
Minten et al. examined data from all patients who underwent TAVR at a single facility from 2008 to 2020. A team of two experienced cardiologists calculated each patient’s baseline SYNTAX Score (SS). Complex CAD was defined as a baseline SS of 23 or more. If a patient underwent pre-TAVR PCI, their SS was calculated again following the procedure.
The study included 604 patients with a mean age of nearly 82 years old. The median follow-up period was 2.8 years. Overall, 57.3% of patients presented with CAD. While 69.9% of those patients had a low SS, the other 30.1% had complex CAD. A total of 30.9% of patients underwent pre-TAVR PCI, and reasonably complete revascularization was achieved in 61.7% of those patients.
All-cause mortality among TAVR patients with CAD
The researchers explored the all-cause mortality rates for these patients after one year, two years, three years and five years. There were “no significant differences” in all-cause mortality between patients with or without CAD after one, two or three years. The same was also true for patients who were or were not treated with PCI, and PCI patients who did and did not undergo a reasonably complete revascularization.
However, the group noted, all-cause mortality after five years was significantly worse for TAVR patients who presented with CAD (55.1% vs. 67.9%). In addition, patients with complex CAD were linked to worse outcomes, “with the most complex group having the worst prognosis.”
Even after five years, though, PCI or a reasonably complete revascularization did not appear to impact a TAVR patient’s mortality risk in any noticeable way.
Cardiovascular mortality and stroke in TAVR CAD patients
When looking at cardiovascular mortality instead of all-cause mortality, the authors noted the exact same trend; no impact after one, two or three years, but a significant impact after five years. Cardiovascular mortality after five years was 25.1% among TAVR patients who also presented with CAD, but 15.1% among TAVR patients with no CAD. Again, the risk of cardiovascular mortality increased progressively as a patient’s CAD got more and more complex.
PCI and a reasonably complete revascularization once again did not make an impact on five-year outcomes.
The authors also wrote that there was “no significant difference” in the risk of stroke among any of the patient groups examined in this analysis. CAD, PCI or a reasonably complete revascularization did not increase or decrease any group’s stroke risk after one year, two years, three years or five years.
Final conclusion shows PCI did not appear to improve TAVR outcomes
“The decision to treat CAD prior to or during TAVR remains controversial, as conflicting data are available about the impact of CAD on short-to-midterm outcomes after TAVR, as well as its complexity and the need for revascularization,” the authors wrote, though they did call out the lack of long-term studies addressing this topic.
The group also emphasized that angiography-guided PCI did not appear to improve TAVR outcomes for any patients included in their analysis.
“The ideal treatment decision protocol for CAD in severe AS patients undergoing TAVR remains to be established, and a more in-depth analysis of lesion severity seems appropriate,” they wrote. “Our findings confirm that CAD complexity is a good marker for future CV risk, while elective angiography-guided PCI in stable CAD does not reduce this risk systematically.”
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.