What question did this study set out to answer?

To evaluate the feasibility and safety of performing invasive coronary angiography screening and ad hoc percutaneous coronary intervention (PCI) during transcatheter aortic valve replacement (TAVR).

August 1, 2017Circulation Cardiovascular InterventionsOpen Access

Optimized Screening of Coronary Artery Disease With Invasive Coronary Angiography and Ad Hoc Percutaneous Coronary Intervention During Transcatheter Aortic Valve Replacement

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Why the study?

Does invasive coronary angiography and ad hoc PCI during TAVR improve outcomes in patients with severe CAD compared to those without CAD or with untreated severe CAD?

Key Points

To evaluate the feasibility and safety of performing invasive coronary angiography screening and ad hoc percutaneous coronary intervention (PCI) during transcatheter aortic valve replacement (TAVR).
Prospective study of 604 patients undergoing coronary artery disease (CAD) screening via invasive coronary angiography at the time of TAVR.
Patients with severe CAD received ad hoc PCI when clinically indicated, proceeding immediately to TAVR in the same setting if the PCI was uncomplicated.
Severe CAD was detected in 22.5% (n=136) of patients, with 8.8% (n=53) receiving uncomplicated same-session PCI and 0.3% (n=2) having TAVR postponed.
At 30 days post-TAVR, all-cause mortality was 2.4%, cardiovascular mortality was 1.4%, disabling stroke occurred in 0.5%, myocardial infarction in 0.8%, life-threatening bleeding in 4.0%, and stage II/III acute kidney injury in 3.3%.
At 2-year follow-up, the composite rate of death, disabling stroke, and myocardial infarction was 10.4% in the TAVR plus PCI group, compared to 15.4% in untreated severe CAD and 14.8% in patients without CAD (P=0.765).

Structured PICO

Does invasive coronary angiography and ad hoc PCI during TAVR improve outcomes in patients with severe CAD compared to those without CAD or with untreated severe CAD?

Population

604 patients undergoing transcatheter aortic valve replacement (TAVR) prospectively included for coronary artery disease (CAD) screening

Intervention

Invasive coronary angiography and ad hoc percutaneous coronary intervention (PCI) during TAVR

Comparator

Patients without CAD, and patients with severe CAD left untreated

Outcome

Composite of death, disabling stroke, and myocardial infarctioncomposite

Screening for CAD with invasive coronary angiography and performing ad hoc PCI during TAVR is feasible, does not increase periprocedural risk, and yields similar long-term outcomes compared to TAVR without PCI.

Implication

Same-session PCI during TAVR appears safe and feasible but should not.

Abstract

Background— We sought to describe an optimized approach to coronary artery disease (CAD) screening and management in patients undergoing transcatheter aortic valve replacement (TAVR). Methods and Results— When invasive coronary angiography showed CAD, the treatment strategy and completeness of revascularization was determined based on coronary anatomy. TAVR was performed in the same setting if percutaneous coronary intervention (PCI) was uncomplicated; otherwise TAVR was postponed. A total of 604 patients undergoing CAD screening at the time of TAVR procedure were prospectively included in this study. Severe CAD was found in 136 patients (22.5%). Among patients with severe CAD, 53 patients (8.8%) underwent uncomplicated PCI. After PCI, TAVR was postponed in 2 patients (0.3%). In 83 patients (13.8%), coronary angiography showed severe CAD that was left untreated. After TAVR, all-cause and cardiovascular 30-day mortality rates were 2.4% and 1.4%, respectively. Disabling stroke, myocardial infarction, and life-threatening bleeding occurred in 0.5%, 0.8%, and 4.0% of patients, respectively. Acute kidney injury II or III rate was 3.3%. At 2 years, all-cause mortality rate was 14.1%. Disabling stroke and myocardial infarction occurred in 2.5% and 1.8% of patients, respectively. Patients undergoing TAVR and PCI in the same session had similar rate of the composite of death, disabling stroke, and myocardial infarction when compared with patients without CAD, and patients with severe CAD left untreated (TAVR+PCI: 10.4%; severe CAD left untreated: 15.4%; no-CAD: 14.8%; P =0.765). Conclusions— In patients undergoing TAVR, screening of CAD with invasive coronary angiography and ad hoc PCI during TAVR is feasible and was not associated with increased periprocedural risks. PCI followed by TAVR in the same session had similar outcomes than TAVR in which PCI was not performed.