Coronary artery disease in patients undergoing transcatheter aortic valve implantation. A single centre registry on prevalence, management and immediate clinical impact

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Severe aortic stenosis with coronary artery disease (n=287). Intervention: Physiologically-guided (FFR) revascularization strategy vs. Optimal medical therapy. Primary outcome: 30-day composite of death, myocardial infarction, percutaneous coronary intervention, and stroke (p=0.01).

Q: What does this research mean for the field?

A physiologically-guided revascularization strategy in TAVI patients with coronary artery disease is feasible, safe, and associated with reduced 30-day major adverse cardiovascular events compared to optimal medical therapy. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Carlo Zivelonghi; Mattia Lunardi; Gabriele Pesarini; Roberto Scarsini; Anna Piccoli; Valeria Ferrero; Leonardo Gottin; Aldo Milano; Giuseppe Faggian; Corrado Vassanelli; Flavio Ribichini

doi:10.1016/j.crvasa.2017.01.012

February 1, 2017Cor et VasaOpen Access

Coronary artery disease in patients undergoing transcatheter aortic valve implantation. A single centre registry on prevalence, management and immediate clinical impact

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Why the study?

There is no consensus on the optimal management of coronary artery disease in patients undergoing transcatheter aortic valve implantation.

Does a physiology-guided revascularization strategy reduce 30-day MACE compared to optimal medical therapy or angiography-guided preventive PCI in patients with CAD undergoing TAVI?

Study Design

Type

Cohort (n=287)

Multicenter

No

Structured PICO

Does a physiology-guided revascularization strategy reduce 30-day MACE compared to optimal medical therapy or angiography-guided preventive PCI in patients with CAD undergoing TAVI?

P

Population

287 consecutive patients (mean age 81.2 years, 56.8% female) undergoing TAVI for severe aortic stenosis, including 123 with coronary artery disease, followed for a mean of 17 months.

E

Exposure

Physiology-guided revascularization strategy (n=47)

C

Comparator

Optimal medical therapy (n=42) or preventive percutaneous coronary intervention (PCI) for angiographically significant lesions (n=34)

O

Outcome

Major adverse cardiovascular events (MACE) at 30 dayscomposite

Main Result

Absolute Event Rate: 0% vs 11.9%

p-value: p=0.01

A physiology-guided revascularization strategy is feasible and safe in patients with CAD undergoing TAVI, potentially reducing 30-day MACE compared to medical therapy or angiography-guided PCI.

Limitations

Retrospective single-centre registry design
Relatively limited sample size
Significant differences in baseline clinical risk among groups (optimal medical therapy group had a higher EuroSCORE)
Historical bias due to different time periods for the strategies (preventive PCI mostly before 2015, FFR-guided strategy mostly since 2015)

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Implication

Observational data on CAD prevalence and management in TAVI patients highlight ongoing variability; leaves open optimal revascularization strategies pending randomized trials.

Abstract

Ăvod: Prevalence ischemickĂŠ choroby srdeÄnĂ (ICHS) se u vĹĄech pacientĹŻ se stenĂłzou aortĂĄlnĂ chlopnÄ (aortic valve stenosis, AVS) pohybuje v rozmezĂ 30 % aĹž 60 %. Dosud nebyla nalezena jednoznaÄnĂĄ shoda ohlednÄ optimĂĄlnĂho zpĹŻsobu lĂŠÄby ICHS u pacientĹŻ s indikacĂ k transkatĂŠtrovĂŠ implantaci aortĂĄlnĂ chlopnÄ (transcatheter aortic valve implantation, TAVI). CĂlem tĂŠto studie bylo stanovit prevalenci, urÄit zpĹŻsob lĂŠÄby i bezprostĹednĂ klinickĂŠ dĹŻsledky ICHS u danĂŠ populace, se zvlĂĄĹĄtnĂm zamÄĹenĂm na proveditelnost a bezpeÄnost metody revaskularizace na zĂĄkladÄ fyziologickĂ˝ch parametrĹŻ.Metody a vĂ˝sledky: Do analĂ˝zy byly zaĹazeny retrospektivnĂ Ăşdaje o celkem 287 po sobÄ nĂĄsledujĂcĂch pacientech indikovanĂ˝ch k TAVI na naĹĄem pracoviĹĄti. NemocnĂ s ICHS (123; 43 %) byli rozdÄleni do tĹĂ skupin podle lĂŠÄebnĂŠ strategie zvolenĂŠ operatĂŠrem: optimĂĄlnĂ farmakoterapie (42 z onÄch 123; 34 %), preventivnĂ perkutĂĄnnĂ koronĂĄrnĂ intervence (percutaneous coronary intervention, PCI) pro angiograficky vĂ˝znamnĂŠ koronĂĄrnĂ lĂŠze (34 ze 123; 28 %) a strategie s pouĹžitĂm fyziologickĂ˝ch parametrĹŻ (47 ze 123; 38 %). V populaci pacientĹŻ s ICHS hodnota logistickĂŠho EuroSCORE dosahovala hodnoty 31 ± 24, pĹiÄemĹž rizikovĂ˝ profil byl vyĹĄĹĄĂ ve skupinÄ s farmakoterapiĂ. ĂspÄĹĄnost vĂ˝konu pĹi pouĹžitĂ TAVI v celĂŠ populaci byla 96 %. KlinickĂŠ vĂ˝sledky po 30 dnech prokĂĄzaly vyĹĄĹĄĂ incidenci zĂĄvaĹžnĂ˝ch kardiovaskulĂĄrnĂch pĹĂhod (major adverse cardiovascular event, MACE) ve skupinĂĄch s optimĂĄlnĂ farmakoterapiĂ a s preventivnĂ PCI (11,9 %, resp. 5,9 %); ve skupinÄ s pouĹžitĂm fyziologickĂ˝ch parametrĹŻ nebyly zaznamenĂĄny ĹžĂĄdnĂŠ pĹĂhody.ZĂĄvÄry: NejlepĹĄĂ zpĹŻsob lĂŠÄby ICHS pĹi TAVI se stĂĄle jeĹĄtÄ hledĂĄ. PĹes pomÄrnÄ omezenou velikost vzorku prokazujĂ naĹĄe zjiĹĄtÄnĂ proveditelnost a bezpeÄnost revaskularizaÄnĂ lĂŠÄby s pouĹžitĂm fyziologickĂ˝ch parametrĹŻ. PotvrzenĂ naĹĄeho zjiĹĄtÄnĂ a zhodnocenĂ dlouhodobĂ˝ch klinickĂ˝ch dĹŻsledkĹŻ si vyĹžĂĄdĂĄ vÄtĹĄĂ studie.

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Cite This Study

Zivelonghi et al. (2017) conducted a cohort in Severe aortic stenosis with coronary artery disease (n=287). Physiologically-guided (FFR) revascularization strategy vs. Optimal medical therapy was evaluated on 30-day composite of death, myocardial infarction, percutaneous coronary intervention, and stroke (p=0.01).

synapsesocial.com/papers/6aaf3b9be8b0ac81b6a5f109 https://doi.org/10.1016/j.crvasa.2017.01.012

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Coronary artery disease in patients undergoing transcatheter aortic valve implantation. A single centre registry on prevalence, management and immediate clinical impact

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Coronary artery disease in patients undergoing transcatheter aortic valve implantation. A single centre registry on prevalence, management and immediate clinical impact

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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