Coronary Events Following TAVI: A Registry

Between 30 and 70% of patients undergoing transcatheter aortic valve replacement (TAVR) present coronary artery disease (CAD). However, the prognostic impact of this condition in the context of TAVR remains uncertain. Even though CAD has been shown to increase post-TAVR one-year mortality rate, the effect of prior, simultaneous or post percutaneous coronary intervention (PCI) remains unclear. 

The ACTIVATION study (Percutaneous Coronary Intervention Prior Transcatheter Aortic Valve Replacement) flailed to show non-inferiority of PCI vs. optimal medical treatment in terms of post-TAVR mortality. Also, post procedure revascularization may have even more questionable outcomes, seeing as coronary access may become more complex. 

The incidence of acute coronary syndrome (ACS) at 2 years seems low, varying between 5 and 10 % of cases. 

Coronary access after TAVR is especially complicated with self-expanding valves (SEVs), vs. balloon-expandable valves (BEVs), due to design differences. However, experienced centers have been shown mostly capable of coronary access. 

In the RE-ACCESS (Reobtain Coronary Ostia Cannulation Beyond Transcatheter Aortic Valve Stent), selective cannulation rate for coronary angiography was 99 % for BEVs and 89 % for SEVs in experienced TAVR centers. However, data predicting the need for PCI and factors influencing CAD management after TAVR are still limited. 

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The aim of this study was to assess the incidence and predictors of new-onset CAD after TAVR, as well as its prognostic impact on mortality, cardiac failure (CF) hospitalization and the combination of both. To this end, the France-TAVI registry (Catheter-Established Aortic Valve Bioprosthesis Registry) was used. It also looked at the impact of valve type (BEV vs SEV) and center type (with or without TAVR program) on long term clinical outcomes. 

The primary outcome was first CAD hospitalization rate during followup. The secondary outcome was the combination of all-cause mortality or CF hospitalization after CAD event. 

Between 2013 and 2021 64,660 patients were included (63.8% SEV and 36.2% BEV patients), and followup approximately for 8 years. Mean patient age was 84, and they were predominantly male, with 12% mean logistic EuroSCORE. The femoral approach was the most commonly used. Among BEVs, the SAPIEN 3 was the most frequently implanted, while the Evolut R led the SEVs.

Post-TAVR CAD was observed in 11.6% of cases (1.5% annual). The main predictors were: male sex, younger age, dyslipidemia, prior CAD, peripheral vascular disease, coronary stenosis >50% prior procedure and acute ST elevation MI (STEMI) during hospitalization for TAVR. 

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As regards the primary outcome, patients with BEVs presented a 12% events rate vs 10.9% for SEVs (p=0.04). The combined outcomes after CAD resulted better in patients undergoing PCI vs those who only underwent coronary angiography or no intervention at all (79.6%, 85.2% and 86.5% respectively; p=0.002). Also, BEV patients showed worse outcomes vs. SEV patients (85.8% vs. 83.8%; p=0.01).

Patients treated in centers with a dedicated TAVR program showed better chances of undergoing PCI (OR: 1.20; CI 95%: 1.01–1.42; p=0.04), especially with BEV (OR: 1.42; CI 95%: 1.18–1.71; p=0.002).

Conclusion 

The annual incidence of CAD after TAVR is low (≈1,5%), but has significant long term clinical impact. Facing CAD, SEV patients present higher all-cause mortality or rehospitalization for CF at 8 years, and a lower chance of undergoing PCI if treated in a center with no TAVR experience. Medical treatment alone is associated to worse prognosis, regardless prosthesis type. 

Though the need for PCI after TAVR is still low, we need to continue developing strategies to facilitate coronary access, including new generation devices and more effective techniques, in addition to promoting the experience sharing among centers.

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.