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Coronary Artery Disease and Transcatheter Aortic Valve Replacement: When to Intervene
Jayendrakumar S Patel1, Samir R Kapadia1
1Section of Interventional Cardiology, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J2-3, Cleveland, OH 44195, USA.
Insights
Revascularization decisions in coronary artery disease patients undergoing transcatheter aortic valve replacement (TAVR) are controversial. Pre-TAVR revascularization is often preferred, but timing depends on individual patient factors and hemodynamic status.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Coronary artery disease (CAD) frequently coexists with aortic stenosis.
- Optimal management of CAD in patients undergoing transcatheter aortic valve replacement (TAVR) is debated.
- Revascularization strategies impact clinical outcomes in this complex patient population.
Purpose of the Study:
- To review and clarify the controversial aspects of coronary revascularization in patients undergoing TAVR.
- To provide guidance on the decision-making process for revascularization timing and strategy.
- To highlight considerations for specific TAVR valve types and patient hemodynamic conditions.
Main Methods:
- Review of current literature and guidelines on coronary revascularization and TAVR.
- Analysis of clinical scenarios and expert consensus.
- Case-based discussion of revascularization sequencing.
Main Results:
- The optimal timing and strategy for coronary revascularization in TAVR patients remain controversial.
- Pre-TAVR revascularization (staged or simultaneous) is generally preferred for unobstructed coronary access, particularly with long self-expanding valves.
- Hemodynamically unstable patients require initial TAVR to address the primary cause of mortality.
Conclusions:
- Revascularization decisions in TAVR patients must be individualized.
- Pre-procedural revascularization offers advantages in specific scenarios.
- Prioritizing TAVR in hemodynamically compromised patients is crucial for survival.
Abstract:
"In patients with coronary artery disease undergoing transcatheter aortic valve replacement (TAVR), the decision of whether to revascularize, which lesions to revascularize, and the optimal timing of revascularization remains controversial. The sequence of revascularization should be made on a case-by-case basis. Pre-TAVR revascularization (staged or simultaneous with TAVR) is preferred due to unobstructed access to coronary ostia and is important to consider especially in cases in which long self-expanding valves are used. In patients who are hemodynamically compromised, the valve should be addressed first, as the most important cause of mortality is heart/multiorgan failure."
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