Coronary artery disease, both obstructive and non-obstructive, often coexists with significant aortic stenosis.
Therapeutic decision-making in this scenario remains controversial, not only regarding the need for treatment, but also about when it should be addressed, considering its pros and cons.
Various analyses have yielded contradictory data, as most lesions are chronic and stable.
Currently, the correct strategy—generally and/or for each individual patient—remains unclear.
A retrospective analysis was conducted at the Cleveland Clinic, from January 2015 to December 2021. It included 1911 patients (70.2%) who did not undergo prior revascularization before transcatheter aortic valve implantation (TAVI). Of these, 1342 had no obstructive coronary artery disease (NO), 116 (6.1%) had intermediate-risk (IR) coronary artery disease, 199 (10.4%) had high-risk (HR) coronary artery disease, and 164 (8.6%) were at extreme risk (ER).
The primary endpoint (PEP) included all-cause death, major adverse cardiac events (MACE), and unplanned revascularization.
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The mean age was 79 years; most patients with coronary artery disease were men and had a higher Society of Thoracic Surgeons (STS) score, as well as a higher incidence of myocardial infarction, atrial fibrillation, hypertension, and peripheral vascular disease.
The ejection fraction was higher in those without coronary artery disease (NO).
Transfemoral access was the most frequent access, while non-femoral accesses were more frequently used in patients with obstructive coronary artery disease. The E. SAPIEN 3 valve was used in approximately 90% of cases.
During the peri-procedural period, there were no significant differences in mortality, bleeding, myocardial infarction, unplanned revascularization, surgery, or the need for ventricular assist devices.
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At 1.3 years of follow-up, there were no differences regarding the PEP, all-cause mortality, or MACE, nor in the need for unplanned revascularization in patients with obstructive coronary artery disease and acute coronary syndromes.
At 79 months of follow-up, there were no differences in all-cause mortality or MACE, but patients with obstructive coronary artery disease had a higher need for unplanned revascularization, which increased with lesion severity.
Conclusion
Percutaneous aortic valve implantation can be safely performed in the presence of chronic obstructive coronary artery disease, with a low relative rate of unplanned revascularizations and acute coronary syndromes at one year.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Impact of untreated chronic obstructive coronary artery disease on outcomes after transcatheter aortic valve replacement.
Reference: Ian Persits, et al. European Heart Journal (2024) 00, 1–11. https://doi.org/10.1093/eurheartj/ehae019.
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