Pre-TAVR Revascularization: Angiographic or Physiological?

In patients undergoing transcatheter aortic valve replacement (TAVR), fractional flow reserve (FFR) guided revascularization is associated with favorable results compared against the traditional angiography guided revascularization. 

Given the complete lack of randomized studies, this observational study is the best we have to decide how to guide revascularization in patients with symptomatic severe aortic stenosis undergoing TAVR. 

The current trend clearly favors the conservative revascularization strategy that treats only proximal lesions as opposed to what we used to do some time ago, treating as many lesions as possible seeing as accessing the coronary arteries post implant might get harder. 

All patients with severe aortic stenosis and coronary artery disease by angiography were included in this retrospective analysis and were divided into two groups: angiography (122/216; 56.5%) vs FFR (94/216; 43.5%) guided TAVR. Patients were followed up at 2 years to assess major events rate. 

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Most of the lesions (78.2%) assessed with FFR resulted negative for ischemia according to the standard cutoff value of 0.80 and were therefore deferred.

The FFR guided group presented a higher event-free survival rate vs. the angiography group (92.6% versus 82.0%; HR, 0.4; CI 95%, 0.2–1.0; p=0.035).

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Patients whose lesions were deferred also presented a higher event-free survival rate than the angiography group (91.4% versus 68.1%; HR, 0.3; CI 95% 0.1–0.6; p=0.001), which is why it seems safe to defer lesions based on FFR in this understudied particular population.

Conclusion

FFR guided revascularization in patients with coronary lesions and severe aortic stenosis undergoing TAVR resulted favorable vs. angiography guided revascularization. 

Original Title: Physiological Versus Angiographic Guidance for Myocardial Revascularization in Patients Undergoing Transcatheter Aortic Valve Implantation.

Reference: Mattia Lunardi et al. J Am Heart Assoc. 2019; 8:e012618.

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