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Determining the Predominant Lesion in Patients With Severe Aortic Stenosis and Coronary Stenoses: A Multicenter Study
Yousif Ahmad1, Jeroen Vendrik2, Ashkan Eftekhari3
1National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.).
Insights
Transcatheter aortic valve implantation (TAVI) improves coronary microcirculation in patients with severe aortic stenosis, irrespective of coronary disease severity. This hemodynamic improvement rivals that of stenting coronary lesions.
Area of Science:
- Cardiology
- Cardiovascular Physiology
Background:
- Severe aortic stenosis (AS) frequently coexists with coronary artery disease, impacting myocardial blood flow and stress response.
- Both conditions affect myocardial perfusion and exertional symptoms.
Purpose of the Study:
- To quantify the impact of severe AS on coronary microcirculation.
- To determine if concomitant coronary disease influences this effect.
- To compare the AS-related microcirculatory changes with those caused by coronary stenoses.
Main Methods:
- Compared 55 severe AS patients undergoing TAVI with 85 non-AS patients undergoing percutaneous coronary intervention for intermediate coronary stenoses.
- Measured coronary pressure and flow at rest and hyperemia, before and after interventions.
Main Results:
- Post-TAVI, microvascular resistance increased (P=0.03), while microvascular reserve improved significantly (P=0.003).
- Improvements were independent of coronary stenosis severity.
- The microcirculatory changes post-TAVI were comparable to stenting lesions with an instantaneous wave-free ratio ≤0.74.
Conclusions:
- TAVI enhances microcirculatory function in severe AS, independent of coronary disease.
- The hemodynamic benefit of TAVI on coronary circulation is similar to stenting intermediate coronary lesions.
- Future trials may use the instantaneous wave-free ratio to guide revascularization in severe AS patients.
Background:
Patients with severe aortic stenosis (AS) often have coronary artery disease. Both the aortic valve and the coronary disease influence the blood flow to the myocardium and its ability to respond to stress; leading to exertional symptoms. In this study, we aim to quantify the effect of severe AS on the coronary microcirculation and determine if this is influenced by any concomitant coronary disease. We then compare this to the effect of coronary stenoses on the coronary microcirculation.
Methods:
Group 1: 55 patients with severe AS and intermediate coronary stenoses treated with transcatheter aortic valve implantation (TAVI) were included. Group 2: 85 patients with intermediate coronary stenoses and no AS treated with percutaneous coronary intervention were included. Coronary pressure and flow were measured at rest and during hyperemia in both groups, before and after TAVI (group 1) and before and after percutaneous coronary intervention (group 2).
Results:
Microvascular resistance over the wave-free period of diastole increased significantly post-TAVI (pre-TAVI, 2.71±1.4 mm Hg·cm·s-1 versus post-TAVI 3.04±1.6 mm Hg·cm·s-1 [P=0.03]). Microvascular reserve over the wave-free period of diastole significantly improved post-TAVI (pre-TAVI 1.88±1.0 versus post-TAVI 2.09±0.8 [P=0.003]); this was independent of the severity of the underlying coronary stenosis. The change in microvascular resistance post-TAVI was equivalent to that produced by stenting a coronary lesion with an instantaneous wave-free ratio of ≤0.74.
Conclusions:
TAVI improves microcirculatory function regardless of the severity of underlying coronary disease. TAVI for severe AS produces a coronary hemodynamic improvement equivalent to the hemodynamic benefit of stenting coronary stenoses with instantaneous wave-free ratio values <0.74. Future trials of physiology-guided revascularization in severe AS may consider using this value to guide treatment of concomitant coronary artery disease.
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