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Transcatheter Aortic Valve Implantation With or Without Percutaneous Coronary Artery Revascularization Strategy: A
Rafail A Kotronias1,2, Chun Shing Kwok1,3, Sudhakar George1,3
1Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom.
Insights
Revascularization before transcatheter aortic valve implantation (TAVI) offers no clear benefit and may increase risks like major vascular complications and 30-day mortality. Individual patient assessment is crucial for deciding on elective revascularization before TAVI.
Area of Science:
- Interventional Cardiology
- Cardiovascular Surgery
- Clinical Outcomes Research
Background:
- Severe aortic stenosis patients with coronary artery disease (CAD) often require both transcatheter aortic valve implantation (TAVI) and coronary revascularization.
- Current guidelines suggest revascularizing CAD before TAVI, but evidence is limited.
- This study evaluates clinical outcomes based on pre-TAVI revascularization in patients with severe aortic stenosis and CAD.
Purpose of the Study:
- To systematically review and meta-analyze clinical outcomes in patients with severe aortic stenosis and CAD who underwent TAVI with or without prior revascularization.
- To assess the impact of pre-TAVI revascularization on major adverse events and mortality.
Main Methods:
- Systematic review and random-effects meta-analysis of published studies.
- Searched Medline and Embase for studies comparing TAVI with versus without percutaneous coronary intervention (PCI).
- Analyzed rates and risks of adverse outcomes, including mortality, myocardial infarction, stroke, and kidney injury.
Main Results:
- Nine studies with 3858 participants were included.
- Pre-TAVI PCI was associated with higher rates of major vascular complications (OR: 1.86) and 30-day mortality (OR: 1.42).
- No significant differences were observed in 30-day cardiovascular mortality, myocardial infarction, acute kidney injury, stroke, or 1-year mortality.
Conclusions:
- Pre-TAVI revascularization does not appear to improve patient-important clinical outcomes.
- Revascularization prior to TAVI may increase the risk of major vascular complications and 30-day mortality.
- Individualized patient evaluation is essential to determine the necessity of elective revascularization before TAVI.
Background:
Recent recommendations suggest that in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation and coexistent significant coronary artery disease, the latter should be treated before the index procedure; however, the evidence basis for such an approach remains limited. We performed a systematic review and meta-analysis to study the clinical outcomes of patients with coronary artery disease who did or did not undergo revascularization prior to transcatheter aortic valve implantation.
Methods And Results:
We conducted a search of Medline and Embase to identify studies evaluating patients who underwent transcatheter aortic valve implantation with or without percutaneous coronary intervention. Random-effects meta-analyses with the inverse variance method were used to estimate the rate and risk of adverse outcomes. Nine studies involving 3858 participants were included in the meta-analysis. Patients who underwent revascularization with percutaneous coronary intervention had a higher rate of major vascular complications (odd ratio [OR]: 1.86; 95% confidence interval [CI], 1.33-2.60; P=0.0003) and higher 30-day mortality (OR: 1.42; 95% CI, 1.08-1.87; P=0.01). There were no differences in effect estimates for 30-day cardiovascular mortality (OR: 1.03; 95% CI, 0.35-2.99), myocardial infarction (OR: 0.86; 95% CI, 0.14-5.28), acute kidney injury (OR: 0.89; 95% CI, 0.42-1.88), stroke (OR: 1.07; 95% CI, 0.38-2.97), or 1-year mortality (OR: 1.05; 95% CI, 0.71-1.56). The timing of percutaneous coronary intervention (same setting versus a priori) did not negatively influence outcomes.
Conclusions:
Our analysis suggests that revascularization before transcatheter aortic valve implantation confers no clinical advantage with respect to several patient-important clinical outcomes and may be associated with an increased risk of major vascular complications and 30-day mortality. In the absence of definitive evidence, careful evaluation of patients on an individual basis is of paramount importance to identify patients who might benefit from elective revascularization.
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