2.1 TAVR and PCI: Which Lesions and in Whom?

These proceedings summarize the educational activity of the 16th Biennial Meeting of the International Andreas Gruentzig Society held January 31-February 3, 2022 in Punta Cana, Dominican Republic

Faculty Disclosures     Vendor Acknowledgments

2022 IAGS Summary Document

Statement of the problem or issue

Patients undergoing transcatheter aortic valve replacement (TAVR) often have concomitant coronary artery disease (CAD). For example, in TAVR registries, prevalence of CAD varies from 28%-74%. Furthermore, since the presence of CAD is a determinant of surgical risk, its prevalence will vary according to the surgical risk of patients in any chosen series. In randomized, controlled trials of TAVR, the prevalence of concomitant CAD varies from 81% (patients at extreme risk) to approximately 60% (those at intermediate risk) to as low as 15% (patients at low surgical risk). Among TAVR patients who have CAD, disease burden varies widely too, and is not always insignificant. In one meta-analysis, disease of the left main or left anterior descending artery was present in 11% and 50% of participants, respectively.¹

There are contradictory results regarding the association between CAD and clinical outcomes with TAVR, as reported in 2 meta-analyses.^2,3 While there is no consistent relationship between the presence of CAD and outcomes, whenever CAD is detected, there is a potential impact based on its overall burden. Patients with a high SYNTAX score (>22) have been shown to have worse outcomes after TAVR than those with a low SYNTAX score.⁴ ­Revascularization may be beneficial in these patients. Of note, the current studies assessing the impact of CAD are predominantly from TAVR patients at intermediate or high surgical risk. The impact of concomitant CAD in low-risk TAVR patients who are likely to have a longer life expectancy is poorly understood. Following TAVR, patients may present with an acute coronary syndrome (ACS), and may require emergent coronary angiography and PCI. Unfortunately, there are limited data on rates of ACS after TAVR. One series suggests a rate as high as 10% at a median follow-up of 25 months after TAVR.⁵ However, this series was in a group of patients with a high rate (68%) of pre-existing CAD, which may have contributed to a higher rate of ACS following TAVR.

Gaps in knowledge

In patients who have concomitant significant CAD and aortic stenosis, there is uncertainty about the benefits and optimal timing of revascularization for those who are candidates for TAVR. Current guidelines recommend that PCI may be considered for those with a coronary artery stenosis of >70%. However, these recommendations are based on very limited data, and the benefit of coronary revascularization remains uncertain. Importantly, the recommendation for coronary artery bypass grafting at the time of surgical AVR is also based on a low level of evidence. Additionally, published studies on PCI in TAVR patients are limited by small numbers, heterogenous design, and selection bias. A large RCT is needed to define the role and benefit of PCI in TAVR patients with concomitant CAD.

Possible solutions and future directions

The COMPLETE TAVR study (A Randomized, Comparative Effectiveness Study of Staged Complete Revascularization with PCI to Treat Coronary Artery Disease vs Medical Management Alone in Patients with Symptomatic Aortic Valve Stenosis undergoing Elective Transfemoral Transcatheter Aortic Valve Replacement; NCT04634240) will determine whether, on a background of guideline-directed medical therapy, a strategy of complete revascularization involving staged PCI using drug-eluting stents to treat all suitable coronary artery lesions is superior to a strategy of medical therapy alone in reducing the composite outcome of cardiovascular death, new myocardial infarction, ischemia-driven revascularization or hospitalization for unstable angina or heart failure in patients who have undergone successful elective TAVR. This large trial with 4000 study participants and over 100 sites will help address this important clinical question.

References

1. Faroux L, Guimaraes L, Wintzer-Wehekind J, et al. Coronary artery disease and transcatheter aortic valve replacement: JACC state-of-the-art review. J Am Coll Cardiol 2019;74(3):362-372. doi:10.1016/j.jacc.2019.06.012

2. Stefanini GG, Stortecky S, Wenaweser P, Windecker S. Coronary artery disease in patients undergoing TAVI: why, what, when and how to treat. EuroIntervention. 2014;10(Suppl U):U69-U75. doi:10.4244/EIJV10SUA10

3. D’Ascenzo F, Verardi R, Visconti M, et al. Independent impact of extent of coronary artery disease and percutaneous revascularisation on 30-day and one-year mortality after TAVI: a meta-analysis of adjusted observational results. EuroIntervention. 2018;14(11):e1169-e1177. doi:10.4244/EIJ-D-18-00098

4. Alperi A, Mohammadi S, Campelo-Parada F, et al. Transcatheter versus surgical aortic valve replacement in patients with complex coronary artery disease. JACC Cardiovasc Interv. 2021;14(22):2490-2499. doi:10.1016/j.jcin.2021.08.073.

5. Faroux L, Munoz-Garcia E, Serra V, et al. Acute coronary syndrome following transcatheter aortic valve replacement. Circ Cardiovasc Interv. 2020;13(2):e008620. Epub 2020 Jan 29. doi:10.1161/CIRCINTERVENTIONS.119.008620