Original title: Impact of coronary artery disease on left ventricular ejection fraction recovery following transcatheter aortic valve implantation. Reference: Freixa X et al. Catheter Cardiovasc Interv. 2014;Epub ahead of print.

This single center study analyzed data form 56 consecutive patients with severe aortic stenosis and LVEF of ≤ 50% undergoing TAVI (transcatheter aortic valve implantation) between March 2006 and May 2012, receiving the Balloon-expandable Sapien valve or Sapien XT valve (Edwards Lifesciences; Irvine, California) and the self-expandable CoreValve (Medtronic; Minneapolis, MN). Approach, type and size of prosthesis were chosen by a multidisciplinary team.

Coronary artery disease (CAD) was defined as the presence of at least 1 stenosis ≥ 70% by visual estimation or a history of revascularization. A total of 44 patients (78.5%) presented coronary artery disease, though half of these patients underwent complete revascularization before valve implantation.

In those with incomplete revascularization vs. those without CAD or with CAD and revascularization, mortality was higher both in hospital (22.2% vs 0% respectively; p= 0.01) and at one year follow up (25.9% vs 3.5% respectively; p=0.019).

The incomplete revascularization group also obtained a higher rate of the composite of death, infarction and rehospitalization, mainly based on rehospitalization due to cardiac failure (37% vs 3.7%; p=0.002). 

At 3 months, patients with complete revascularization or absence of CAD saw better LVEF recovery than those with incomplete revascularization (p=0.007) and this tendency persisted at 12 months (p=0.020). According to the multivariable analysis, the last independent predictors of LVEF recovery at three months were higher baseline LVEF (p=0.004) and complete revascularization (p<0.001).

Conclusion

The present study shows an independent association between complete revascularization and recovery of LVEF in those patients with severe aortic stenosis undergoing TAVI.

Editorial Comment

It is important to weigh the risks and benefits of this procedure in very elderly patient with complex lesions. It is clear that complete revascularization will always be the better choice; however, most of operators, when treating 80 to 90 year old patients with severe aortic stenosis and chronic total occlusion of the right coronary artery with good collaterals, will first try TAVI. 

When possible, PCI is always recommended but, if not possible, we should consider the adverse impact on prognosis. Perhaps, in the clinical context of this population of patients, “reasonable” revascularization might be as good as complete revascularization.

SOLACI