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Impact of Coronary Diameter Stenosis and Proximal Lesion Location on Outcomes Following PCI in Patients Undergoing
Matti Riihiniemi1, Jasmine Melissa Marquard2, Jarkko Piuhola1,3
1Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu, Finland (M.R., J.P., M.N., J.J.).
Insights
Percutaneous coronary intervention (PCI) benefits patients with high-grade coronary artery stenosis undergoing transcatheter aortic valve implantation. Stenosis location did not significantly alter PCI
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- Optimal management of coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) is not fully established.
- Coronary stenosis characteristics may influence treatment outcomes in this patient population.
Purpose of the Study:
- To investigate the impact of coronary stenosis diameter and location on outcomes after percutaneous coronary intervention (PCI) in patients undergoing TAVI.
- To analyze whether PCI offers benefits compared to conservative management for CAD in TAVI patients based on stenosis severity and location.
Main Methods:
- A prespecified subanalysis of the NOTION-3 trial involving patients with severe aortic stenosis and stable CAD randomized to PCI or conservative management.
- Patients were stratified by diameter stenosis (<90% or ≥90%) and stenosis location (proximal or nonproximal).
- Primary outcome was major adverse cardiovascular events (MACE): all-cause death, myocardial infarction, or urgent revascularization.
Main Results:
- PCI significantly reduced MACE in patients with high-grade stenosis (≥90% diameter stenosis) compared to conservative treatment (24% vs. 37%).
- No significant benefit of PCI was observed in patients with lower-grade stenosis (<90% diameter stenosis) (31% vs. 33%).
- PCI showed a trend towards benefit for proximal stenosis (26% vs. 38%), but stenosis location did not significantly modify outcomes.
Conclusions:
- Percutaneous coronary intervention (PCI) provides significant benefit for patients undergoing transcatheter aortic valve implantation (TAVI) with high-grade coronary artery stenosis.
- Stenosis location did not emerge as a significant factor modifying the outcome of PCI in this TAVI cohort.
- These findings suggest that high-grade stenosis is a key determinant for considering PCI in TAVI patients with stable CAD.
Background:
Optimal treatment of coronary artery disease in patients undergoing transcatheter aortic valve implantation remains debated. Here, our aim was to analyze the impact of the diameter and location of coronary stenosis on outcomes in patients undergoing percutaneous coronary intervention (PCI) with transcatheter aortic valve implantation.
Methods:
This study was a prespecified subanalysis of the NOTION-3 trial (Nordic Aortic Valve Intervention), which randomized patients with severe symptomatic aortic stenosis and physiologically significant stable coronary artery disease to receive either PCI or conservative treatment of coronary artery disease with transcatheter aortic valve implantation. In this substudy, patients were stratified according to diameter stenosis (<90% or ≥90%) and stenosis location (proximal or nonproximal). The primary outcome was major adverse cardiovascular event, a composite of all-cause death, myocardial infarction, and urgent revascularization.
Results:
Of 455 randomized patients, 184 (40%) had diameter stenosis <90% and 271 (60%) ≥90%. A total of 294 (65%) patients had at least 1 proximal stenosis, while in 161 (35%) patients stenoses were nonproximal. At a median follow-up of 2 years (interquartile range, 1-4), PCI reduced the absolute risk of major adverse cardiovascular event by 13% in patients with diameter stenosis ≥90% (PCI 24% versus conservative treatment 37%; hazard ratio, 0.53 [95% CI, 0.34-0.82]), whereas no benefit was observed in patients with diameter stenosis <90% (31% versus 33%; hazard ratio, 1.04 [95% CI, 0.62-1.73]; P for interaction=0.051). PCI reduced major adverse cardiovascular events in case of proximal stenosis (26% versus 38%; hazard ratio, 0.61 [95% CI, 0.40-0.93]), although the difference in effect remained nonsignificant when compared with patients with nonproximal stenosis (28% versus 32%; hazard ratio, 0.91 [95% CI, 0.52-1.61]; P for interaction=0.27).
Conclusions:
The beneficial effect of PCI in patients undergoing transcatheter aortic valve implantation with physiologically significant stable coronary artery disease was seemingly pronounced in patients with high-grade stenosis, while stenosis location was not found to modify the outcome despite an almost similar beneficial effect with PCI in patients with proximal stenosis.
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