¿What Should We Do About Significant Coronary Lesions in TAVR?

Aortic stenosis and coronary artery disease (CAD) share risk factors, which means significant lesions will coexist in approximately 50% of cases, especially in the elderly patients. 

When it comes to surgery, there is no question as to the approach. However, for TAVR patietns, the evidence remains inconclusive, seeing as we only have one randomized study and a few registries providing contradicting information. 

The NOTION 3 (randomized, open, superiority study) included 455 patients with severe aortic stenosis and CAD (significant lesion to ≥2.5 mm vessel with <0.80 FFR or ≥90% visual angiographic lesion). 227 of these patients received PCI and 228 were treated conservatively. 

Primary end point was a composite of all-cause death, myocardial infarction (MI) or emergency revascularization.

Both groups presented similar characteristics: mean age 81, one third were women, had 3% STS score and 60% ejection fraction. There were no significant differences in prevalence of PCI, MI, CABG, diabetes, stroke, atrial fibrillation, peripheral artery disease or COPD.

Read also: ESC 2024 | NOTION 3 Trial: Percutaneous Coronary Intervention in Patients with a Planned Transcatheter Aortic Valve Implantation.

Mean SYNTAX score was 9. PCI was done before TAVR in 74% of cases, during TAVR in 17%, and less frequently after procedure. 60% of valves were self-expanding while the rest were balloon expandable.  

At two-year follow-up, primary end point resulted in favor of PCI (26% vs. 36%, 0.71 HR; CI 95%, 0.51 to 0.99; P = 0.04). There were no significant differences in all-cause or cardiovascular mortality, MI or emergency revascularization, or in terms of major or minor bleeding, stent thrombosis or kidney failure. 

Conclusion

In patients with coronary artery disease undergoing TAVR, PCI was associated with a lower risk of all-cause mortality, myocardial infarction or emergency revascularization at 2-year follow-up. 

Original Title: PCI in Patients Undergoing Transcatheter Aortic-Valve Implantation. NOTION 3 Trial.

Reference: J. Lønborg, R. Jabbari, et al. NEJM.org. DOI: 10.1056/NEJMoa2401513.