Effect of Concomitant Coronary Artery Disease on Procedural and Late Outcomes of Transcatheter Aortic Valve Implantation

doi:10.1016/j.athoracsur.2009.12.033

The Annals of Thoracic Surgery

Volume 89, Issue 3, March 2010, Pages 758-767

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.

https://doi.org/10.1016/j.athoracsur.2009.12.033 Get rights and content

Background

Previous coronary artery bypass grafting increases predicted operative risk for conventional valve replacement, according to the Society of Thoracic Surgeons risk algorithm. Additionally, the presence of coronary artery disease (CAD) has been demonstrated to increase procedural risk with conventional aortic valve replacement. Significant coexisting CAD requires preemptive percutaneous coronary intervention (PCI) in patients under consideration for transcatheter aortic valve implantation (TAVI). This study examined the impact of previous coronary artery bypass grafting or PCI on procedural outcomes and overall survival in patients having TAVI.

Methods

Two hundred and one high-risk patients were enrolled in two international feasibility studies from December 2005 to February 2008 for the treatment of aortic stenosis using TAVI. Thirty patients were excluded from analysis due to failure to successfully deploy the valve in the aortic annulus. Data were collected concurrently using an ad hoc database that included operative and long-term survival. Previous cardiovascular intervention prior to TAVI was used to identify the existence of concomitant CAD. Logistic regression along with Kaplan-Meier estimates were employed to establish the association between CAD and survival from TAVI.

Results

Overall mortality after TAVI was significantly higher among the CAD group (35.7%) in contrast with the non-CAD patients (18.4%), p = 0.01. Logistic regression analysis found that patients who had CAD were 10.1 times more likely to die (95% confidence interval 2.1 to 174.8) within 30 days of the procedure than those who did not. Proportional hazards analysis established that the risk of dying at any point in time was 2.3 times higher among the patients with CAD (95% confidence interval 1.29 to 4.17). Kaplan-Meier survival curves demonstrate improved long-term survival among patients without CAD.

Conclusions

Coexisting coronary artery disease negatively impacts procedural outcomes and long-term survival in patients undergoing TAVI, and implies that risk assessment and anticipated outcomes might be inaccurate due to stratification as isolated aortic valve replacement rather than AVR+CABG. Comparison of procedural outcomes, based on operative approach without controlling for unequal distribution of CAD in the cohorts, are likely invalid.

Section snippets

Patients and Methods

This study is a retrospective review of data records of 201 patients enrolled in two studies. It was reviewed and approved by the North Texas Institutional Review Board at Medical City Dallas with a waiver of consent.

Between December of 2005 and February of 2008, 201 high-risk patients were enrolled in two feasibility studies utilizing the stainless-steel balloon expandable Sapien valve (Edwards Lifesciences, Irvine, CA) at 12 participating centers in North America and Europe. A total of 40

Results

A total of 201 patients were identified as having undergone attempted TA-AVI (n = 40) or TF-AVI (n = 161) from 12 centers in North America and Europe between December 2005 and February 2008 as part of transapical and transfemoral feasibility trials. In the 40 patient TA-AVI trial, five patients were excluded from analysis due to technical complications that resulted in embolization of the valve or malplacement such that conversion to an open procedure was required. Table 1 characterizes the 35

Comment

It is axiomatic that aortic valve replacement is the treatment of choice for patients with critical aortic stenosis. However, certain patient populations have been excluded from conventional surgical therapy due to perceived elevated operative risk [12, 13]. Transcatheter aortic valve implantation, either retrograde through a transfemoral approach or antegrade through a transapical approach, has become a clinical reality in the treatment of critical aortic stenosis in high-risk patients. Early

References (16)

T. Walther et al.
Transapical aortic valve implantation: step by step
Ann Thorac Surg
(2009)
E. Grube et al.
Percutaneous aortic valve replacement for severe aortic stenosis in high-risk patients using second and current third generation self-expanding CoreValve prosthesis
J Am Coll Cardiol
(2007)
T.M. Dewey et al.
Reliability of risk algorithms in predicting early and late operative outcomes in high-risk patients undergoing aortic valve replacement
J Thorac Cardiovasc Surg
(2008)
L.G. Svensson et al.
United States feasibility study of transcatheter insertion of a stented aortic valve by the left ventricular apex
Ann Thorac Surg
(2008)
M.B. Leon et al.
Transcatheter aortic valve replacement in patients with critical aortic stenosis: rationale, device description, early clinical experiences, and perspectives
Semin Thorac Cardiovasc Surg
(2006)
P. Varadarajan et al.
Clinical profile and natural history of 435 nonsurgically managed patients with severe aortic stenosis
Ann Thorac Surg
(2006)
E.R. Nowicki et al.
Multivariate prediction of in-hospital mortality associated with aortic and mitral valve surgery in northern New England
Ann Thorac Surg
(2004)
I. Florath et al.
Current determinants of operative mortality in 1400 patients requiring aortic valve replacement
Ann Thorac Surg
(2003)

There are more references available in the full text version of this article.

Cited by (224)

Results of hybrid procedures of concomitant coronary artery bypass grafting and transcatheter aortic valve implantation (TAVI)
2024, Cirugia Cardiovascular
La enfermedad coronaria puede estar presente en un 40-75% de los pacientes con estenosis aórtica severa que se someten a implante transcatéter de la válvula aórtica (TAVI). Se pretende evaluar la seguridad de un procedimiento híbrido en que se realiza simultáneamente la cirugía de revascularización coronaria y TAVI respecto a la cirugía convencional de revascularización coronaria e implante de prótesis aórtica con circulación extracorpórea.
Se analizaron los pacientes intervenidos de TAVI concomitantemente a revascularización coronaria sin circulación extracorpórea, de forma consecutiva, desde que se comenzó a realizar este procedimiento en el 2017 hasta el último paciente intervenido en el 2020 (n = 19), y se compararon con los casos intervenidos de implante de prótesis aórtica biológica, con circulación extracorpórea, concomitantemente a revascularización coronaria quirúrgica, en el 2021 (n = 24). Se utilizaron los parámetros unificados del Valve Academic Research Consortium 3 (VARC-3).
Respecto a las variables preoperatorias, se encontraron diferencias estadísticamente significativas en la edad media (77,89 ± 5,91 años en el grupo TAVI respecto a 70,33 ± 5,48 años en el grupo de cirugía convencional; p < 0,001), y en la tasa de vasculopatía (63,2% respecto a 25%; p = 0,012). No se encontraron diferencias en el número de anastomosis coronarias realizadas entre ambos grupos. En los resultados posoperatorios, solo se encontraron diferencias estadísticamente significativas en la tasa de regurgitación periprotésica (47,4% vs. 8,3%; p = 0,005).
El TAVI concomitantemente a cirugía de revascularización coronaria se demuestra segura sin diferencias estadísticamente significativas en los objetivos primarios de mortalidad, tasa de ictus y de reintervenciones, así como en los objetivos combinados de éxito técnico, del dispositivo, de seguridad precoz y de eficacia clínica.
Coronary artery disease may be present in 40-75% of patients with severe aortic stenosis who undergo transcatheter aortic valve implantation (TAVI). The aim is to evaluate the safety of a hybrid procedure in which coronary artery bypass grafting and TAVI are performed simultaneously with respect to conventional coronary artery bypass grafting and aortic prosthesis implantation with cardiopulmonary bypass.
Patients who underwent TAVI concomitantly with coronary revascularization off-pump were analyzed, consecutively, from when this procedure began in 2017 until the last patient operated on in 2020 (n = 19), compared with the cases operated on for biological aortic prosthesis implantation, with cardiopulmonary bypass, concomitantly with surgical coronary revascularization, in the last year 2021 (n = 24). Unified Valve Academic Research Consortium 3 (VARC-3) parameters were used.
Regarding the preoperative variables, statistically significant differences were found in mean age (77,89 ± 5,91 years in the TAVI group compared to 70,33 ± 5,48 years in the conventional surgery group; p < 0.001), and in the rate of vascular disease (63,2% vs. 25%; p = 0,012). No differences were found in the number of coronary anastomoses performed between the two groups. In the postoperative results, only statistically significant differences were found in the rate of paravalvular regurgitation (47,4% vs. 8,3%; p = 0.005).
TAVI concomitantly with coronary artery bypass grafting has been shown to be safe with no statistically significant differences in the primary endpoints of mortality, stroke rate, and reoperations, as well as in the combined endpoints of technical success, device success, early safety, and of clinical efficacy.
Clinical Outcomes of Transcatheter Aortic Valve Replacement With and Without Percutaneous Coronary Intervention—An Updated Meta-Analysis and Systematic Review
2023, Current Problems in Cardiology
Transcatheter aortic valve replacement (TAVR) is indicated for high-risk patients with severe degenerative aortic stenosis (AS). Given the shared risk factors and coexistence of obstructive coronary artery disease (CAD) and AS, there is inconsistent clinical data regarding potential survival benefits of paired percutaneous coronary intervention (PCI) with TAVR procedures. We performed a literature search using PubMed, Embase, and Cochrane Library from inception through June 2023 assessing the impact of concomitant PCI in patients with obstructive CAD undergoing TAVR. The primary outcomes were 30-day all-cause mortality, 30-day cardiovascular mortality, and 6 months-1 year all-cause mortality. Secondary outcomes included 30-day myocardial infarction, stroke, major bleeding complications, and acute kidney injury (AKI). A total of 11 studies involving 2804 patients were included in the final analysis. Compared to patients undergoing TAVR alone, the TAVR+PCI group showed no significant difference in 30-day all-cause mortality (RR 0.90, CI 0.66, 1.22, P = 0.49), 30-day cardiovascular mortality (RR 0.71 CI 0.44, 1.14, P = 0.16), or 6 months-1 year all-cause mortality (RR 0.94, CI 0.75, 1.18, P = 0.57). Regarding secondary outcomes, 30-day myocardial infarction was higher in the TAVR+PCI group (RR 3.09, CI 1.26, 7.57, P = 0.01), with no significant differences noted in rates of 30-day stroke (RR 1.14, CI 0.56, 2.33, P = 0.72), major bleeding/vascular complications (RR 1.11, CI 0.79, 1.56, P = 0.55), and AKI (RR 1.07, CI 0.75, 1.54, P = 0.71). Concomitant PCI does not confer any mortality benefit in patients with obstructive CAD and high-grade AS undergoing TAVR. Further trials are needed to confirm our findings.
Outcomes of Transcatheter Aortic Valve Replacement With and Without Index Chronic Total Occlusion of Coronary Artery: A Propensity Matched Analysis
2023, American Journal of Cardiology
Transcatheter aortic valve replacement (TAVR) utilization is increasing, along with procedural success. Coronary angiography is frequently performed before the TAVR procedure for coronary artery disease workup. Chronic total occlusion (CTO) of the coronary artery shares common risk factors with aortic stenosis and could be challenging, especially in terms of procedural safety. The outcomes of TAVR among patients with concomitant CTO are not extensively studied. We analyzed the National Inpatient Sample database between October 2015 and December 2020 to evaluate the clinical characteristics, procedural safety, and outcomes among patients who underwent TAVR who had concomitant CTO lesions. A total of 304,330 TAVRs were performed between 2015 and 2020, 5,235 of which (1.72%) were in patients with TAVR-CTO and 299,095 (98.28%) in those with TAVR–no CTO. After propensity matching, there was no difference in the odds of in-hospital mortality (adjusted odds ratio [aOR] 1.28, 95% confidence interval [CI] 0.94 to 1.75, p = 0.11). However, TAVR-CTO was associated with an increased incidence of acute myocardial infarction (aOR 1.27, 95% CI 1.05 to 1.53, p = 0.01), cardiac arrest (aOR, 2.60, 95% CI 1.64 to 4.11, p <0.0001), and need for mechanical circulatory support (aOR 2.6, 95% CI 1.88 to 3.59, p <0.0001). There was no difference in the incidence of stroke, major bleeding, complete heart block, or requirement for permanent pacemaker between the 2 groups. However, the TAVR-CTO cohort had a slightly greater length of stay and total hospitalization cost. TAVR is a relatively safe procedure among those with concomitant CTO lesions; however, it is associated with a greater incidence of acute myocardial infarction, cardiac arrest, and requirement for mechanical circulatory support.
Impact of concomitant aortic stenosis on the management and outcomes of acute myocardial infarction hospitalizations in the United States
2022, American Heart Journal Plus: Cardiology Research and Practice
To evaluate the prevalence, management and outcomes of concomitant aortic stenosis (AS) in admissions with acute myocardial infarction (AMI).
We used the HCUP-NIS database (2000–2017) to identify adult AMI admissions with concomitant AS. Outcomes of interest included prevalence of AS, in-hospital mortality, use of cardiac procedures, hospitalization costs, length of stay, and discharge disposition.
Among a total of 11,622,528 AMI admissions, 513,688 (4.4 %) were identified with concomitant AS. Adjusted temporal trends revealed an increase in STEMI and NSTEMI hospitalizations with concomitant AS. Compared to admissions without AS, those with AS were on average older, of female sex, had higher comorbidity, higher rates of NSTEMI (78.9 % vs 62.1 %), acute non-cardiac organ failure, and cardiogenic shock. Concomitant AS was associated with significantly lower use of coronary angiography (45.5 % vs 64.4 %), percutaneous coronary intervention (20.1 % vs 42.5 %), coronary atherectomy (1.7 % vs. 2.8 %) and mechanical circulatory support (3.5 % vs 4.8 %) (all p < 0.001). Admissions with AS had higher rates of coronary artery bypass surgery and surgical aortic valve replacement (5.9 % vs 0.1 %) compared to those without AS. Admissions with AMI and AS had higher in-hospital mortality (9.2 % vs. 6.0 %; adjusted OR 1.12 [95 % CI 1.10–1.13]; p < 0.001). Concomitant AS was associated with longer hospital stay, more frequent palliative care consultations and less frequent discharges to home.
In this 18-year study, an increase in prevalence of AS in AMI hospitalization was noted. Concomitant AS was associated with lower use of guideline-directed therapies and worse clinical outcomes among AMI admissions.
Outcome of Patients With Severe Aortic Stenosis and Normal Coronary Arteries Undergoing Transcatheter Aortic Valve Implantation
2021, American Journal of Cardiology
Coronary artery disease and severe aortic stenosis (AS) often coexist. This study sought to investigate the impact of normal coronary arteries as negative risk marker in patients undergoing transcatheter aortic valve implantation (TAVI). Consecutive patients with severe AS undergoing TAVI were dichotomized according to the presence or absence of normal coronary arteries, defined as absence of coronary lesions with diameter stenosis ≥30% in vessels ≥1.5 mm in diameter on coronary angiogram in patients without prior coronary revascularization. The primary end point was 1-year mortality. Out of 987 patients with severe AS undergoing TAVI, 258 (26%) patients had normal coronary arteries. These patients were younger, more likely women, and had lower EuroSCORE II and STS risk scores. Although mortality at 30 days was similar in the normal coronary artery and the coronary atherosclerosis groups (3.1% vs 5.6%, p = 0.11), it was lower in those with normal coronary arteries at 1 year (8.9% vs 17%, p = 0.003). In multivariable analysis, the presence of normal coronary arteries on coronary angiogram independently predicted 1-year mortality (adjusted HR 0.57, 95% CI 0.37 to 0.90, p = 0.02). In conclusion, this study defined normal coronary arteries as negative risk marker in patients with severe AS undergoing TAVI.
Impact on clinical outcome of ventricular arrhythmias in patients undergoing transcatheter aortic valve implantation
2024, Journal of Cardiovascular Medicine

View all citing articles on Scopus

View full text

Original articleAdult cardiacEffect of Concomitant Coronary Artery Disease on Procedural and Late Outcomes of Transcatheter Aortic Valve Implantation

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

Ann Thorac Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

Semin Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Original article
Adult cardiac
Effect of Concomitant Coronary Artery Disease on Procedural and Late Outcomes of Transcatheter Aortic Valve Implantation