Do the Best Coronary Revascularization Prior TAVR

The presence of coronary artery disease (CAD) in patients with aortic stenosis is high, reaching 50% to70% of cases. This poses a great challenge as to what strategy to use and the things we can do.

Even though it has been shown complete revascularization is beneficial, it is often difficult to achieve. Instead, reasonable incomplete revascularization should have better evolution (similar to complete revascularization) than incomplete revascularization (ICR) defined as a Residual Syntax Score (rSS) >8 in TAVR. However, there is contradicting information in TAVR.

A meta-analysis of 3107 patients included in 6 studies was carried out, with a follow up between 0.7 and 3 years, comparing mortality amongst patients with ICR, reasonable ICR and no CAD disease.

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ICR was associated to higher global mortality, compared against the rest of the groups.  The absence of CAD presented lower mortality compared to ICR (OR 1.85; 95% CI 1.42-2.240; P<0.01), reasonable ICR (OR, 1.69; 95% CI 1.26-2.28; P<0.001) or both groups combined (OR; 1.71; 95% CI, 1.36-2.16; P<0.001).

In reasonable ICR patients, there were no differences with those not presenting CAD (OR, 1.11; 95% CI, 0.89-1.39; P=0.33).

Conclusion

These outcomes suggest that in patients with coronary artery disease undergoing TAVR, guided rSS revascularization might bring significant benefits as regards mortality. Reasonable revascularization offers a precious opportunity to improve patient prognosis.

Commentary

These data suggest we should make an effort to obtain the best revascularization (in one or more procedures) in patients presenting significant CAD that are TAVR candidates.

However, note that the present indication poses a great challenge, seeing that it is about a high risk group where most patients are elderly. This involves higher risk in complex PCI, which we should perform taking special care as regards contrast volume, vascular complications and bleeding (the latter notably improved by the use of radial access).

Courtesy of Dr. Carlos Fava.

Original title: Impact of Coronary Artery Revascularization Completeness on Outcomes of patients With Coronary Artery disease Undergoing Transcatheter Aortic Valve Replacement. A Meta-analysis of Studies Using the residual SYNTAX Score (Synergy Between PCI With Taxus and Cardiac Surgery).

Reference: Guy Witberg, et al . Circ cardiovasc Interv 2018;11:e006000.DOI: 10.1161.

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