Original Title: Outcomes in Patients with Transcatheter Aortic Valve Replacement and Left Main Stenting. The TAVR-LM Registry. Reference: TarunChakravarty et al. Journal of the American College of Cardiology, Vol 67, N° 8, 2016.

Courtesy of Dr. Santiago F. Coroleu. 

High surgical risk patients with severe aortic stenosis and significant left main aortic arterydiseaseare often treated combining transcatheter aortic valve replacement (TAVI) and left main stenting (LM PCI). Outcomes on the combination of TAVI + LM PCI have not been reported so far.

Clinical, echocardiographic, tomographic and angiographic characteristics were retrospectively collected from 204 patients undergoing TAVI with LM PCI. In all, out of 167 patients treated with LM PCI prior to TAVI, 128 control cases were matched 1:1 with 1188 control patients submitted to TAVI without LM revascularization.

Mortality at one year (9.4% vs. 10.2%, p=0.83) was similar in both groups. Mortality at one year post TAVI + LM PCI was no different in: 1) patients with unprotected LM vs. protected LM (7.8% vs. 8.1%, p=0.88), 2) patients submitted to LM PCI within three months prior to TAVI (7.4% vs. 8.6%, p=0.61), 3) patients with ostial vs. non ostial LM stents (10.3% vs. 15.6%, p = 0.20). Emergency unplanned LM PCI due to TAVI complications, resulted in mortality increase at 30 days (15.8% vs. 3.4%, p = 0.013) and one year (21.1% vs. 8.0%, p = 0.071), compared to programmed LM PCI.

Conclusion
Despite anatomical proximity of the aortic annulus and the left main coronary artery, TAVI + LM PCI is safe and technically feasible, with short and medium term results comparable to those of patients submitted to TAVI alone. These results suggest that the combination of TAVI and LM PCI is a reasonable option for highsurgical risk patients.

Editorial Comment
The presence of severe LM stenosis in patients with severe aortic stenosis is among the enrolment exclusion criteria of studies assessing intermediate risk for TAVI (Partner II, SURTAVI).

The anatomical proximity of the LM to the aortic annulus is a matter of concern when considering a transcatheter aortic valve replacement, especially in patients with LM PCI prior to TAVI.

AGAINST: this study presents a number of limitations from the statistical and methodological point of view (retrospective, small sample, indirect comparison after “matching” patients in two groups, not to mention 30% ofTAVI + LM PCI patients could not be matched).

FOR: useful study for the clinical practice of real life, for it contributes with data on how to treat certain patients (severe LM stenosis + severe aortic stenosis + high surgical risk), unavailableuntil now, since these kind of patients had not been assessed so far.

Courtesy of Dr. Santiago F. Coroleu. 
Santiago del Estero Cardiology Institute, Argentina.