FRANCE TAVI Registry: Coronary Adverse Events After TAVI

Between 30% and 70% of patients undergoing transcatheter aortic valve implantation (TAVI) have coronary artery disease (CAD). However, the prognostic impact of CAD in this context is not fully understood. While CAD has been shown to increase mortality one year after TAVI, the effect of percutaneous transluminal coronary angioplasty (PTCA) before, during, or after the procedure remains uncertain.

The ACTIVATION study (Percutaneous Coronary Intervention prior to Transcatheter Aortic Valve Implantation) failed to demonstrate the non-inferiority of PTCA compared to medical treatment regarding post-TAVI mortality. Furthermore, subsequent revascularization may be even more controversial, as coronary access becomes more complex.

The incidence of acute coronary syndrome (ACS) at two years also appears to be very low, 5%-10% of cases. Coronary access after TAVI is more complex, especially with self-expanding valves (SEV) compared to balloon-expandable valves (BEV), due to their design. Despite this difficulty, experienced centers have achieved a selective cannulation rate for coronary angiography (CA) of 99% for BEV and 89% for SEV, according to the RE-ACCESS study (Reobtain Coronary Ostia Cannulation Beyond Transcatheter Aortic Valve Stent).

Data predicting the need for PTCA and factors influencing the management of CAD after TAVI remain limited.

The aim of this study was to assess the incidence and predictive factors of post-TAVI CAD, as well as its prognostic impact on mortality, hospitalization for heart failure (HF), and a composite of both, using the France-TAVI registry (a registry of transcatheter aortic valve bioprostheses). The impact of valve design (BEV vs. SEV) and the effect of being treated in a center with or without TAVI capabilities on long-term outcomes were also analyzed.

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The primary endpoint (PEP) was the rate of first hospitalization for CAD during follow-up. The secondary endpoint (SEP) was a composite of all-cause mortality or HF hospitalization after CAD.

Results

Researchers included 64,660 patients (63.8% SEV, 36.2% BEV) between 2013 and 2021, with a follow-up of approximately eight years. The mean age was 84 years, and most subjects were men, with a mean logistic Euroscore of 12%. Transfemoral access was the most frequent alternative used. Among valve prostheses, SAPIEN 3 was the most common in the BEV group, while Evolute R was the most common in the SEV group.

About 11.6% of patients (1.5% annually) experienced CAD. Its main predictors after discharge were male sex, younger age, dyslipidemia, history of CAD, peripheral vascular disease, >50% coronary stenosis prior to TAVI, and ST-elevation myocardial infarction (STEMI) during hospitalization for TAVI.

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Regarding the PEP, patients with BEV had an incidence of 12%, compared to 10.9% in SEV (P = 0.04). After CAD, combined outcomes were better in patients undergoing PTCA than in those who only underwent coronary angiography or no intervention (79.6%, 85.2%, and 86.5%, respectively; P = 0.002). Similarly, adverse events were more frequent in patients with BEV than with SEV (85.8% vs. 83.8%; P = 0.01). Patients treated in centers with TAVI capabilities were more likely to undergo PTCA (odds ratio [OR]: 1.20 [95% confidence interval [CI]: 1.01-1.42]; P = 0.04), especially if they had a BEV (OR: 1.42 [95% CI: 1.18-1.71]; P = 0.002).

Conclusion

The annual incidence of CAD after TAVI is low (1.5%) but has a significant impact on long-term outcomes. Patients with SEV have higher all-cause mortality or HF rehospitalization at eight years and are less likely to undergo PTCA in centers without TAVI capabilities. Medical treatment only for CAD is associated with a worse prognosis, regardless of the type of prosthesis used.

While the need for PTCA remains relatively low after TAVI, optimizing valve design to facilitate coronary access, implementing advanced techniques, and sharing knowledge in specialized centers remain key to improving clinical outcomes.

Original Title: Coronary Events After Transcatheter Aortic Valve Replacement Insights From the France TAVI Registry.

Reference: Sandra Zendjebil, MD et al JACC Cardiovasc Interv. 2025; 18: 229–243.