Progression of coronary artery disease in patients undergoing transcatheter aortic valve replacement: a quantitative flow ratio analysis

Background Transcatheter Aortic Valve Replacement (TAVR) is indicated for patients with severe aortic stenosis (AS) to improve their quality of life and survival, however, many of these patients have concomitant coronary artery disease (CAD). The natural history of CAD progression in patients following TAVR remains unknown. Quantitative Flow Ratio (QFR) is validated angiography-based computational method that estimates the functional severity of CAD. Purpose This study aimed to (1) determine the rate of CAD progression in patients following TAVR, (2) compare CAD progression between self-expanding and balloon-expanding valves, using QFR. Methods Patients who underwent TAVR at a large tertiary university hospital (2013–2024) with pre- and post-TAVR invasive coronary angiograms (CA) were retrospectively analyzed. CAD progression was defined as QFR <0.80 or a decrease of ≥0.05 in post-TAVR CA (Figure 1). Results 90 patients met the inclusion criteria and underwent analysis. The mean age was 74.22 years, 55.6% were male and 78.9% were Caucasian. A medical history of hypertension (87.6%), type-2 diabetes (48.3%), prior myocardial infarction (28.1%) was present. The mean left ventricular ejection fraction (EF) was 54.27%. After a median follow-up of 756.5 days (IQR 261–1327), 85.6% of patients (77/90) demonstrated CAD progression in at least one coronary artery. Progression was observed in 60.0% of patients in the left anterior descending (LAD) artery, 48.9% in the left circumflex (LCX) artery, and 48.9% in the right coronary artery (RCA) (Figure 1). Late progression (≥2 years post-TAVR) occurred in 42.2% of patients, while 43.4% had early progression (<2 years post-TAVR). Kaplan-Meier (KM) estimates of overall progression was significantly higher in the self-expanding compared to the balloon-expanding valves (1 year: 39.4% vs. 21.9%, 2 years: 47.4% vs. 39.3%, p=0.038) (Figure 2). In all three major coronary arteries, KM estimates of progression were numerically higher in self-expanding valves compared to balloon-expanding valves (LAD: 34.53% vs. 23.82%, p=0.06; LCX: 34.91% vs. 24.82%, p=0.10; RCA: 30.68% vs. 24.14%, p=0.21). Conclusions Most patients exhibited CAD progression post-TAVR, with an overall significantly higher incidence among self-expanding valve recipients at two years. This study suggests device selection can have an impact on disease progression. Furher studies should be conducted to better understand the mechanism of CAD progression post-TAVR.