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Published on: June 3, 2018
Percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation: a systematic
Hugo M Aarts1,2, Nicole D van Hemert1, Timion A Meijs1,2
1Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
Insights
Percutaneous coronary intervention (PCI) before transcatheter aortic valve implantation (TAVI) for significant coronary artery disease (CAD) did not improve survival or reduce cardiac events. However, PCI increased major bleeding risk within 30 days.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- Revascularization significance in patients undergoing transcatheter aortic valve implantation (TAVI) with coronary artery disease (CAD) remains unclear.
- Current guidelines recommend percutaneous coronary intervention (PCI) for significant proximal CAD in TAVI patients, despite limited evidence.
Purpose of the Study:
- To systematically review and meta-analyze clinical outcomes comparing TAVI with and without preceding PCI in patients with significant CAD.
- To evaluate the impact of PCI on mortality, cardiac death, stroke, myocardial infarction, and major bleeding.
Main Methods:
- Systematic literature search for studies comparing TAVI with and without PCI in patients with significant CAD.
- Meta-analysis of 14 studies involving 3838 patients (1806 received PCI).
- Primary endpoints included all-cause mortality, cardiac death, stroke, myocardial infarction, and major bleeding.
Main Results:
- No significant differences in all-cause mortality at 30 days, 1 year, or beyond.
- No significant differences in cardiac death, stroke, or myocardial infarction risk.
- PCI before TAVI was associated with a higher risk of major bleeding within 30 days (OR: 0.66; 95% CI: 0.46-0.94).
Conclusions:
- Concomitant PCI in patients with significant CAD undergoing TAVI showed no significant short- or long-term clinical outcome benefits.
- PCI prior to TAVI increased the risk of major bleeding within 30 days.
- Further randomized controlled trials are needed due to the risk of bias in included studies.
Objective:
The importance of revascularisation of significant coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) is unclear. Despite the lack of randomised controlled trials comparing different revascularisation strategies, guidelines currently recommend percutaneous coronary intervention (PCI) in patients with significant proximal CAD undergoing TAVI.
Methods:
In this systematic review and meta-analysis, a systematic search was conducted to identify studies comparing TAVI with and without PCI in patients with significant CAD on pre-TAVI coronary angiography. Endpoints were all-cause mortality, cardiac death, stroke, myocardial infarction and major bleeding.
Results:
In total, 14 studies were included, involving 3838 patients, of whom 1806 (47%) underwent PCI before TAVI. All-cause mortality did not differ significantly between TAVI with and without preceding PCI at 30 days, 1 year and > 1 year. There were no significant differences in risk of cardiac death, stroke or myocardial infarction between the groups. However, TAVI performed with PCI resulted in a higher risk of major bleeding within 30 days after TAVI (odds ratio: 0.66; 95% confidence interval: 0.46-0.94).
Conclusion:
This systematic review and meta-analysis showed no significant differences in clinical outcomes between patients with concomitant significant CAD who were treated with TAVI with and without preceding PCI at both short- and long-term follow-up. However, there was a higher risk of major bleeding at 30 days in patients undergoing TAVI with preceding PCI. In the context of serious risk of bias in the included studies, results of randomised controlled trials are warranted.
