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Progression of Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Replacement: A Quantitative
Jason Galo1, Abdullah Al Qaraghuli2, Cheng Zhang1
1Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington DC, USA.
Insights
Coronary artery disease (CAD) progresses in most patients after transcatheter aortic valve replacement (TAVR). Progression is linked to valve type and baseline disease severity, warranting further study.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Imaging
Background:
- Coronary artery disease (CAD) progression post-transcatheter aortic valve replacement (TAVR) is not well understood.
- Coronary hemodynamics and atherosclerosis changes after TAVR require further investigation.
- Quantitative coronary angiography (QCA) and quantitative flow ratio (QFR) provide objective assessments of coronary disease.
Purpose of the Study:
- To evaluate CAD progression (anatomic and hemodynamic) after TAVR using QCA and QFR.
- To compare outcomes between self-expanding valves (SEV) and balloon-expandable valves (BEV).
Main Methods:
- Retrospective analysis of 92 patients with pre- and post-TAVR coronary angiography.
- QCA and QFR performed on major coronary arteries to assess CAD progression.
- Defined progression by QCA diameter stenosis increase or QFR decrease over time.
Main Results:
- High rates of CAD progression observed: 96.6% by QCA and 85.6% by QFR.
- QFR showed significantly greater progression with SEV compared to BEV (p=0.038).
- CAD progression by QCA and QFR correlated with baseline disease severity.
Conclusions:
- Most TAVR patients exhibit CAD progression on serial angiography.
- Valve type influences QFR-defined progression; both QCA and QFR correlate with baseline severity.
- Further research on coronary progression after TAVR is necessary.
Background:
The progression of coronary artery disease (CAD) following transcatheter aortic valve replacement (TAVR) is poorly understood. Changes in coronary hemodynamics after TAVR and their relationship with atherosclerosis remain an active area of investigation. Quantitative coronary angiography (QCA) and quantitative flow ratio (QFR) offer objective, reproducible assessments of coronary disease burden, hemodynamics, and progression.
Aims:
To evaluate anatomic and hemodynamic progression of CAD in select patients undergoing TAVR using QCA and QFR, and to compare outcomes by valve type-self-expanding valves (SEV) versus balloon-expandable valves (BEV).
Methods:
A total of 92 patients who underwent TAVR and had both pre- and post-TAVR invasive coronary angiography (CA) were retrospectively analyzed. QCA and QFR analyses were performed on major coronary arteries. CAD progression was defined in 2 ways: (1) QCA diameter stenosis (DS) increase ≥ 10% or baseline < 50% and follow‑up ≥ 50%; (2) QFR decrease ≥ 0.05 or baseline QFR > 0.80 and follow-up ≤ 0.80. Clinical and echocardiographic data, statin use, and antiplatelet therapy were assessed longitudinally.
Results:
Over a median follow-up of 756 days (IQR 254-1302), CAD progression in patients with clinically indicated post-TAVR CA was observed in 96.6% of patients using QCA and in 85.6% of patients using QFR. Among vessel subsegments, CAD progression by QCA was greatest in the LAD proximal and mid segments (60.99% and 58.46%, respectively), and lowest in distal LCX and distal RCA (37.63%, 39.04%, respectively). CAD progression by QFR was significantly greater in SEV when compared to BEV (1-year: 39.4% vs. 21.9%; 2-year: 47.4% vs. 39.3%, log rank p = 0.038). There was no statistically significant difference in the QCA-defined CAD progression between SEV and BEV, though a numerically higher progression was seen in SEV.
Conclusions:
Most TAVR recipients undergoing clinically indicated repeat CA demonstrate CAD progression on serial angiography. By QFR, progression is influenced by valve type, while by QCA and QFR, trended with baseline disease severity. Further investigation into coronary progression following TAVR is warranted.
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