Incomplete Revascularization Is Associated with Mortality in TAVR

Courtesy of Dr. Carlos Fava.

TAVR has proven to be beneficial for inoperable and high-risk patients, as well as for intermediate-risk patients. However, while many comorbidities have been analyzed, the presence, severity, and impact of coronary disease has not been well studied yet.

This study analyzed 1270 patients who underwent TAVR. They presented >50% lesions in a major epicardial vessel and were divided into 3 groups:

• Without coronary disease: 817 patients (64%).
• With non-severe coronary disease (SYNTAX score <22): 331 patients (26.5%).
• With severe coronary disease (SYNTAX score <22):

Furthermore, the study analyzed the residual SYNTAX score (rSS) by dividing patients into those with “reasonable” incomplete revascularization (rSS <8) and with incomplete revascularization (rSS >8).

Also read: “When Is the Optimal Timing for PCI: Before or During TAVI”.

Patients with severe coronary disease presented more comorbidities and higher need for medication.

Over a follow-up of 1.9 years (0.8-3.5), 312 (24.5%) patients died. In the Kaplan-Meier analysis, mortality among patients without coronary disease was similar to that of those with coronary disease (21.9% vs. 29.1%). Between groups of patients with coronary disease, mortality was higher among those with severe disease (51.9% vs. 26.1%; p < 0.001). Incomplete revascularization patients presented higher mortality rates than patients with reasonable incomplete revascularization (23.2% vs. 45.1%; p < 0.001).

Also read: “TAVI Intermediate Risk: Reality or Passion?”.

The multivariate analysis showed that the presence of both coronary disease and incomplete revascularization (as opposed to reasonable incomplete revascularization) was associated with increased mortality.

Conclusion

Only coronary disease was associated with increased mortality after TAVR. More complete revascularization pre-TAVR attenuated the association between coronary disease and mortality.

Editorial Comment

This analysis shows that severe coronary disease (SYNTAX score >22) with significant residual ischemia (rSS >8) effectively modifies prognosis. Otherwise, prognosis remains the same.

In consequence, we must attempt a revascularization as complete as possible before TAVR, taking into account that these are high-risk patients with severe coronary disease, total occlusions and extremely calcified lesions. In that sense, angioplasty implies a great challenge that, consequently, should perhaps be addressed with two interventions in certain cases, while trying to reduce complications (particularly those related to renal impairment).

Courtesy of Dr. Carlos Fava.

Original Title The Prognostic Effects of Coronary Disease Severity and Completeness of Revascularization on Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement.

Reference: Guy Witberg, et al. J Am Coll Cardiol Intv 2017;10:1428-35.

We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.