Aortic stenosis shares risk factors with coronary artery disease (CAD), and its prevalence varies according to age, reaching approximately 50% or more in some registries.
Deciding when to treat and the need for percutaneous intervention presents a challenge. It has been established that epicardial stenosis at proximal level, or the medial segment, requires intervention, especially with ischemia, even though this last consideration remains controversial.
At present, there is no clear indication on how to best proceed in this scenario.
There was a retrospective analysis of the EVERY-VALVE, including 2,233 patients undergoing TAVR: 274 (12.3%) received TAVR and concomitant (simultaneous) percutaneous coronary intervention (coPCI); 226 (10.1%) received PCI within 60 days prior TAVR in a stepwise approach (swPCI); and 1,733 (77.6%) were not treated with PCI (noPCI).
Primary end point was all-cause mortality at 3 years. Mean age was 81, STS score 4.1%, and CAD presence was 61.7%.
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CoPCI patients we mostly men and had lower ejection fraction, with no significant differences in other factors. The balloon expandable was the most used valve (85.6%), with successful implantation rate 94%. Patients undergoing coPCI received more contrast, more stents, and PCI to the left main coronary artery. The incidence of bleeding was higher in patients undergoing PCI, as was kidney function deterioration.
Hospital stay was longer in the coPCI group and two thirds of these patients received DAPT with aspirin and clopidogrel.
At one year followup, there were no significant differences in all-cause mortality. Primary end point at 3 years showed no differences, with 34.2% for coPCI, 31.9% for swPCI and 34% for noPCI patients. Neither were there differences in cardiovascular mortality (19.6% for coPCI, 14.8% for swPCI and 18.9% for noPCI).
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BARC 3 bleeding or superior, as well as kidney deterioration higher than stage 1, were associated to a threefold increase in mortality.
Conclusion
Concomitant PCI in TAVR patients seems comparable in this retrospective analysis. Stepwise PCI shows similar procedural success and device rates, as well as long term mortality.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Concomitant percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation.
Reference: Julius Fischer, et al. Catheter Cardiovasc Interv. 2024;103:186–193.
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