Aortic stenosis is associated to significant coronary artery disease (CAD) in nearly 50% of cases.
When we decide to treat aortic disease using surgery, it has been established we should also treat heart disease.
However, when using transcatheter aortic valve replacement (TAVR), this is still unclear, given that in many occasions we see stable lesions where it is hard to determine whether they produce ischemia, or whether to do a complete or incomplete revascularization.
Even though there are several analyses and one randomized study, the information remains controversial, and we do not know if we should treat before, during or after TAVR, for each of these options presents different benefits and limitations.
The REVASC-TAVI Registry included 2402 patients with significant stable CAD and aortic stenosis undergoing percutaneous coronary intervention (PCI) and TAVR.
Primary end point was all cause mortality at 2 years and co-primary end point was all cause mortality, stroke, MI, and hospitalization for cardiac failure at 2 years.
Patients were divided into those who received complete (CR) vs. Incomplete revascularization (IR).
Because the groups were too different, patients were matched using propensity score, leaving 657 in each group.
Mean age was 83, 60% were men, 85% hypertensive, 32% diabetic, 16% COPD, 16% CABG, 38% PCI, 23% AMI, 7% stroke, 9% definite pacemaker and 1.5% was V-in-V.
The presence of atrial fibrillation was 26%, ejection fraction 55% and mortality STS Score was 5%.
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RI patients presented more 2 and 3 vessel lesions.
The valves used were balloon-expandable SAPIENS 3 and Ultra and self-expanding Evolut R / PRO / PRO+.
Primary end point resulted 21.6% vs. 18.2% (hazard ratio 0.88 [95% CI, 0.66–1.18]; P=0.38) and co-primary 29.0% vs. 27.1% (hazard ratio 0.97 [95% CI, 0.76–1.24]; P=0.83) for RC and RI respectively. There was not much difference in all-cause mortality, stroke, MI and hospitalization for cardiac failure at 2-year followup, neither were there differences between patients undergoing staged PCI or during TAVR, or the different prespecified groups looked into.
Conclusion
The present analysis of the REVASC-TAVI Registry has shown that, among patients with TAVR and stable CAD, complete revascularization staged or concomitant with TAVR, resulted similar to incomplete revascularization as regards all-cause mortality, stroke, MI and rehospitalization for cardiac failure at 2 years, considering the clinical and anatomical situation.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Management of Myocardial Revascularization in Patients With Stable Coronary Artery Disease Undergoing Transcatheter Aortic Valve Implantation
Reference: Giuliano Costa, et al. Circ Cardiovasc Interv. 2022;15:e012417. DOI: 10.1161/CIRCINTERVENTIONS.122.012417.
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