“Ad Hoc” PCI during TAVR: No Impact on Safety or Long Term Outcomes

According to a recent study published in Circulation Cardiovascular Interventions, screening for coronary artery disease (CAD) with an invasive coronary angiography  (as part of the protocol prior TAVR)  and performing PCI and TAVR in the same session, has no impact on periprocedural safety or on long term outcomes.

Study outcomes offer new hope, especially as regards using TAVR in higher risk populations.

Of course, this strategy is controversial and needs to be refined; moreover, we could avoid the prior invasive angiography altogether. In this regard, the external strategy could be screening for CAD non-invasively with CT (this study is mandatory) and proceeding to ad hoc angioplasty together with TAVR, if needed.   

This study enrolled 604 consecutive patients with invasive angiography as part of the protocol studies prior TAVR.

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PCI was performed with no more than 80 ml contrast. If successful ─without complications and a stable patient─ operators would immediately continue with TAVR.

Severe coronary disease was found in 136 patients (22.5%). Of these patients, 53 received ad hoc PCI and the remaining 83 did not. This was due to several reasons, among others: very distal stenosis or in several small vessels (49.4%), chronic total occlusion (31.3%), severely calcified lesions (12%) or lesions in necrotic areas (7.2%).

In two patients TAVR was put off for a month, given too much contrast was used during PCI.

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At 30 days, all-cause mortality was 2.4% and cardiovascular mortality was 1.4%. Disabling stroke, infarction, life threatening bleeding, and major and minor bleeding rates were also low with 0.5%, 0.8%, 4.0%, 17.9% and 4.8%, respectively.

At two years, all-cause mortality was 12.9%, stroke was 2.5% and infarctions reached 1.8%.

Not only was the safety outcome significant, there were no differences between strategies either. At 2 years, the composite of death, stroke and infarction was 10.7% for those undergoing PCI and TAVR in the same session, 14.8% for patients with untreated CAD undergoing TAVR alone (for reasons above mentioned), and 14.5% for those undergoing TAVR alone given the absence of CAD (p=0.85 for all comparisons).

Despite the favorable figures, it is obvious this strategy does not work for all patients and the challenge lies in finding the subgroup that will benefit the most, to guarantee the highest standards of safety and the best cost effective ratio.

Original title: Optimized screening of coronary artery disease with invasive coronary angiography and ad hoc percutaneous coronary intervention during transcatheter aortic valve replacement.

Reference: Barbanti M et al. Circ Cardiovasc Interv. 2017; Epub ahead of print.

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