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Updated: May 21, 2025
Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement
Published on: March 26, 2018
Optimal timing for percutaneous coronary intervention in patients undergoing transcatheter aortic valve replacement:
Pedro E P Carvalho1, Bruno Ramos Nascimento2, Douglas M Gewehr3
1Center for Coronary Artery Disease, Minneapolis Heart Institute, Minneapolis, USA. Electronic address: https://twitter.com/PedroEPCarvalho/statsus/1896031840806539676.
Insights
For patients needing both transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI), performing PCI in a staged procedure after TAVR reduces risks of stroke, heart attack, and death. This staged approach offers better outcomes than concurrent or no PCI.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Health Outcomes Research
Background:
- Optimal timing for percutaneous coronary intervention (PCI) in patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear.
- Coexisting coronary artery disease (CAD) and aortic stenosis (AS) present complex treatment challenges.
Purpose of the Study:
- To compare the clinical outcomes of different PCI timings relative to TAVR in patients with AS and CAD.
- Evaluate staged PCI versus concomitant PCI versus TAVR alone.
Main Methods:
- Systematic literature search of MEDLINE, Embase, and Cochrane databases.
- Network meta-analysis of frequentist random-effects models to calculate odds ratios (OR) and 95% confidence intervals (CI).
- P-score analysis for treatment ranking based on efficacy in preventing adverse events.
Main Results:
- Analysis included 2 randomized controlled trials and 24 observational studies (10,901 patients).
- Staged PCI was associated with significantly lower rates of stroke (OR 0.54), myocardial infarction (OR 0.54), and 30-day all-cause mortality (OR 0.62) compared to concomitant PCI and TAVR.
- Subgroup analysis indicated staged PCI post-TAVR yielded the lowest all-cause mortality; P-score analysis favored staged PCI for preventing stroke and myocardial infarction.
Conclusions:
- In patients with AS and CAD undergoing TAVR, a staged PCI approach is linked to reduced rates of stroke, myocardial infarction, and short-term mortality.
- Staged PCI, particularly after TAVR, appears to be the optimal strategy for managing combined AS and CAD.
Background:
The optimal timing for percutaneous coronary intervention (PCI) in patients undergoing transcatheter aortic valve replacement (TAVR) is uncertain.
Objectives:
To compare different PCI timings in patients with CAD undergoing TAVR.
Methods:
MEDLINE, Embase, and Cochrane were systematically searched for studies comparing different timings of PCI in patients with aortic stenosis and coronary artery disease (CAD) undergoing TAVR. PCI in a staged procedure to TAVR and PCI concomitantly to TAVR were compared with TAVR alone without PCI. A frequentist random-effects network meta-analysis calculates the odds ratio (OR) with a 95 % confidence interval (CI). Treatments were ranked using P-score analysis.
Results:
Two randomized controlled trials and 24 observational studies comprising 10,901 patients with aortic stenosis and CAD were included. Compared with PCI and concomitant TAVR, staged PCI was associated with lower rates of stroke (OR 0.54; 95 % CI 0.37-0.78), myocardial infarction (OR 0.54; 95 % CI 0.31-0.91), and all-cause mortality at 30 days (OR 0.62; 95 % CI 0.41-0.95). In addition, a subgroup analysis showed that staged PCI performed after TAVR is associated with the lowest rates of all-cause mortality of all strategies. In P-score analysis, staged PCI presented the highest likelihood of preventing stroke and myocardial infarction.
Conclusion:
In patients with aortic stenosis and CAD undergoing TAVR, staged PCI is associated with lower rates of stroke, myocardial infarction, and short-term mortality compared with other timings.
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