Disease prevalence in patients with severe aortic stenosis is highly variable: from 80% in inoperable patients to only 15% according to the most recent research including low-risk patients.
Given the high mortality observed in patients with heart disease, guidelines suggest considering coronary bypass revascularization in those in need of a valve replacement.
This experience with surgical patients was transferred to the first works on transcatheter aortic valve replacement (TAVR), where coronary angiography was included in the mandatory assessment protocol and revascularization was highly recommended.
A research study lead by Dr. Faroux et al. was recently published in JACC: Cardiovascular Interventions: it assessed 1197 patients (mean age: 81 years) treated with angioplasty before (94%) or during (6%) TAVR.
Half of patients presented multivessel lesions, many of which were complex (50% were calcified lesions and 46%, bifurcation lesions).
Read also: Diastolic Dysfunction and TAVR: Prognosis before and after Procedure.
Despite patient age and lesion complexity, only 3.3% had target lesion failure at 2 years of follow-up.
Based on these data, authors assert the safety of pre-TAVR revascularization—which is clear—, but the question remains: were those revascularizations necessary?
Given the experience accumulated over the years and device improvement, the chances of acute ischemia during the procedure are minimal and in the sickest patients we are unable to see the benefit of revascularization.
Read also: Last Bastion of Bare Metal Stents Finally Falls.
Nowadays, TAVR is reaching lower-risk populations who have a long life expectancy after the procedure. Some have therefore suggested that previous revascularization is even more important for fear of difficulties with coronary access. However, this is still speculation.
Several major ongoing works aim to learn about the usefulness of functional assessment to decide on revascularization, although this does not solve the problem of future coronary access, if needed.
Interventionists should be familiar with potential difficulties and options to solve problems. Guidewire catheters with smaller bends, accessing the ostium with the guidewire from the outside and then approach the catheter, and properly choosing the valve stent strut to access are skills that should be developed, especially if a prior TAVR patient presents with an ongoing infarction.
Original Title: Coronary Revascularization Before Transcatheter Aortic Valve Replacement.
Reference: Cindy L. Grines et al. JACC Cardiovasc Interv. 2020 Nov 23;13(22):2614-2616. https://doi.org/10.1016/j.jcin.2020.08.018.
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