The association between aortic stenosis and coronary disease is common, since both conditions share pathogenesis, risk factors, and symptoms. Transcatheter aortic valve replacement (TAVR) is currently indicated for high-risk and inoperable patients. It also appears as a valid alternative for the treatment of intermediate-risk patients, and it could soon be indicated for low-risk patients.
Coronary disease has a negative impact on this patient group. That is the reason why we should look for the best strategy: because we are starting to use TAVR in low-risk patients.
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Among patients enrolled, 462 cases (52%) presented coronary disease, and 169 of these patients (37%) underwent coronary angioplasty before TAVR.
The presence of obstructive coronary disease was associated with male sex, acute coronary syndromes, lower gradient (maximum and mean), and the lack of use of transfemoral access. Additionally, affected patients presented lower New York Heart Association functional class and a lower ejection fraction.
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At 30 days, the rates of mortality among patients with obstructive coronary disease were higher (8.7% vs. 5.1%; p = 0.003). After correction for confounding factors, obstructive coronary disease was identified as an independent predictor of mortality (hazard ratio [HR]: 1.74; 95% confidence intervals [CIs]: 1.03-2.94; p = 0.0037).
In patients with coronary disease, neither bSs nor rSs were predictors of mortality.
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Conclusion
In the assessment for TAVR, obstructive coronary disease at baseline has an independent negative impact on the short-term prognosis. However, neither baseline nor residual Ss values have prognostic ability in patients undergoing TAVR. Prior revascularization in these cases seems to improve survival to levels comparable with those of patients without baseline coronary disease.
Editorial Comment
The presence of coronary disease associated with aortic stenosis is about 40%-75%.
This is the first study showing coronary disease as an independent predictor of mortality at 30 days and prior angioplasty as a means to reduce it, making it comparable to that of patients without obstructive coronary disease.
While several articles have shown that rSs >8 is associated with mid- and long-term mortality, this analysis does not encourage an aggressive strategy, so as to implement prior revascularization thus improving 30-day survival.
Courtesy of Dr. Carlos Fava.
Original title: Concomitant Coronary Artery Disease and its Management in Patients Referred to Transcatheter Aortic Valve Implantation. Insights from the POL-TAVI Registry.
Reference: Zenon Huczek, et al. Catheter Cardiovasc Interv 2018;91:115-123.
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