Determining the Predominant Lesion in Patients With Severe Aortic Stenosis and Coronary Stenoses

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Severe aortic stenosis and coronary stenoses (n=140). Intervention: Transcatheter aortic valve implantation (TAVI) vs. Pre-intervention (baseline). Primary outcome: Microvascular reserve over the wave-free period of diastole (p=0.003).

Yousif Ahmad; Jeroen Vendrik; Ashkan Eftekhari; James P. Howard; Christopher Cook; Christopher Rajkumar; Iqbal Malik; Ghada Mikhail; Neil Ruparelia; Nearchos Hadjiloizou; Sukhjinder Nijjer; Rasha Al‐Lamee; Ricardo Petraco; Takayuki Warisawa; Gilbert Wijntjens; Karel T. Koch; Tim P. van de Hoef; Guus A. de Waard; Mauro Echavarría‐Pinto; Angela Frame; Nilesh Sutaria; Gajen Kanaganayagam; Ben Ariff; Jon Anderson; Andrew Chukwuemeka; Michael Fertleman; Sasha Koul; Juan F. Iglesias; Dárrel P. Francis; Jamil Mayet; Patrick W. Serruys; Justin E. Davies; Javier Escaned; Niels van Royen; Matthias Götberg; Christian Juhl Terkelsen; Evald Høj Christiansen; Jan J. Piek; Jan Baan; Sayan Sen

doi:10.1161/circinterventions.119.008263

November 22, 2019Circulation Cardiovascular InterventionsOpen Access

Determining the Predominant Lesion in Patients With Severe Aortic Stenosis and Coronary Stenoses

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Key result

TAVI significantly improved microvascular reserve from 1.88 to 2.09 (p=0.003), providing a hemodynamic benefit equivalent to stenting a coronary lesion with an iFR <0.74.

Figures

Why the study?

Both severe aortic stenosis and coronary artery disease influence myocardial blood flow, but the quantitative effect of severe AS on coronary microcirculation relative to coronary stenoses was unclear.

Does TAVI improve coronary microcirculatory function in patients with severe aortic stenosis and concomitant coronary disease?

Study Design

Type

Observational (n=140)

Multicenter

Yes

Structured PICO

Does TAVI improve coronary microcirculatory function in patients with severe aortic stenosis and concomitant coronary disease?

P

Population

140 patients, including 55 with severe aortic stenosis and intermediate coronary stenoses undergoing TAVI, and 85 with intermediate coronary stenoses undergoing PCI, evaluated for acute microcirculatory changes.

I

Intervention

Transcatheter aortic valve implantation (TAVI) or percutaneous coronary intervention (PCI) with paired physiological measurements pre- and post-intervention.

C

Comparator

Pre-intervention (baseline) hemodynamics

O

Outcome

Change in microvascular reserve and microvascular resistance over the wave-free period of diastole measured immediately post-intervention.surrogate

Main Result

Absolute Event Rate: 2.09% vs 1.88%

p-value: p=0.003

Limitations

Patients undergoing PCI did not have severe aortic stenosis and there were other baseline differences between the groups.
Post-TAVI measurements were all made acutely within the same procedure.
Inability to determine if concomitant treatment of CAD would have afforded additional benefits or reduced TAVI benefits.
Larger proportion of patients in the PCI group had more severe coronary lesions with lower iFR values.
Patients undergoing PCI did not have severe AS and had baseline differences compared to TAVI group
Measurements were acute, missing longer-term remodeling effects
Uncertainty regarding combined TAVI and PCI effects
Greater proportion of more severe coronary lesions in the PCI group

Implication

TAVI provides significant improvement in microcirculatory function equivalent to treating a coronary stenosis with iFR <0.74, suggesting physiology can help guide treatment of concomitant CAD in severe AS.

Abstract

BACKGROUND: Patients with severe aortic stenosis (AS) often have coronary artery disease. Both the aortic valve and the coronary disease influence the blood flow to the myocardium and its ability to respond to stress; leading to exertional symptoms. In this study, we aim to quantify the effect of severe AS on the coronary microcirculation and determine if this is influenced by any concomitant coronary disease. We then compare this to the effect of coronary stenoses on the coronary microcirculation. METHODS: Group 1: 55 patients with severe AS and intermediate coronary stenoses treated with transcatheter aortic valve implantation (TAVI) were included. Group 2: 85 patients with intermediate coronary stenoses and no AS treated with percutaneous coronary intervention were included. Coronary pressure and flow were measured at rest and during hyperemia in both groups, before and after TAVI (group 1) and before and after percutaneous coronary intervention (group 2). RESULTS: =0.003]); this was independent of the severity of the underlying coronary stenosis. The change in microvascular resistance post-TAVI was equivalent to that produced by stenting a coronary lesion with an instantaneous wave-free ratio of ≤0.74. CONCLUSIONS: TAVI improves microcirculatory function regardless of the severity of underlying coronary disease. TAVI for severe AS produces a coronary hemodynamic improvement equivalent to the hemodynamic benefit of stenting coronary stenoses with instantaneous wave-free ratio values <0.74. Future trials of physiology-guided revascularization in severe AS may consider using this value to guide treatment of concomitant coronary artery disease.

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Cite This Study

Ahmad et al. (2019) conducted an observational in Severe aortic stenosis and coronary stenoses (n=140). Transcatheter aortic valve implantation (TAVI) vs. Pre-intervention (baseline) was evaluated on Microvascular reserve over the wave-free period of diastole (p=0.003). TAVI significantly improved microvascular reserve from 1.88 to 2.09 (p=0.003), providing a hemodynamic benefit equivalent to stenting a coronary lesion with an iFR <0.74.

synapsesocial.com/papers/6a219b42153b2036cbf1e44d https://doi.org/10.1161/circinterventions.119.008263