Impact of coronary artery disease in elderly patients undergoing transcatheter aortic valve implantation: Insight from the Italian CoreValve Registry

doi:10.1016/j.ijcard.2012.03.089

International Journal of Cardiology

Volume 167, Issue 3, 10 August 2013, Pages 943-950

https://doi.org/10.1016/j.ijcard.2012.03.089 Get rights and content

Abstract

Background

Coronary artery disease (CAD) commonly coexists with degenerative aortic stenosis. The impact of CAD in patients undergoing transcatheter aortic valve implantation (TAVI) raises concerns due to the lack of comprehensive and consistent data on this topic. We sought to evaluate the impact of CAD on clinical outcomes in patients undergoing TAVI.

Methods

Consecutive patients(N = 663) who underwent TAVI with the 18-French CoreValve ReValving System (CRS) (Medtronic Inc, MN USA) from June 2007 through December 2009 at 14 institutions across Italy were included in this prospective web-based registry. Four patients were excluded from the analysis due to failure to successfully release the prosthesis inside the native aortic valve. Previous percutaneous or surgical myocardial revascularizations were used to identify the existence of concomitant CAD (N = 251; 38%). The primary endpoint was the incidence of Major Adverse Cerebrovascular and Cardiac Events (MACCE) and all-cause death in CAD and no-CAD groups.

Results

Patients with CAD were no more likely to develop MACCE within 12-months of the procedure than those who did not (CAD group vs no-CAD group, 15.7% vs 18.3%; adjusted hazard ratio [HR] 0.76; 95% confidence interval [CI] 0.42 to 1.36; p = 0.353). The 12-month mortality was 14.5% and 15.9% in CAD group and no-CAD group, respectively (adjusted HR 0.74; 95% CI 0.40 to 1.36; p = 0.331).

Conclusions

Coexisting CAD does not impact procedural outcomes and mid-term incidence of MACCE and survival in elderly patients undergoing TAVI with CRS prosthesis.

Introduction

Coronary artery disease (CAD) commonly coexists with degenerative aortic stenosis (AS) [1], [2]. Approximately half of patients undergoing surgical aortic valve replacement (AVR) have concomitant CAD. The presence of concomitant CAD is associated with an increased operative mortality in patients undergoing AVR [3], [4]. The current standard of care is to combine coronary artery bypass grafting (CABG) with AVR in the same session [5] as several studies have documented an improved short and long term survival [6] and lower rate of perioperative myocardial infarction [7] in patients with significant CAD undergoing combined AVR and CABG compared to those receiving only AVR.

In the last few years, Transcatheter Aortic Valve Implantation (TAVI) has rapidly matured into a viable treatment alternative for patients with severe AS at high risk for conventional AVR [8]. However, despite significant experience with two devices under post-marketing surveillance in Europe (the Edwards SAPIEN prosthesis [Edwards Lifesciences, CA, USA] and the CoreValve ReValving System [CRS] [Medtronic Inc, MN, USA]) [9], [10], there is scant data on the impact and optimal timing and extent of revascularization in patients who are currently offered TAVI [11], [12]. Data from large centers with expertise in TAVI, AVR as well as surgical and percutaneous revascularization would help elucidate the most appropriate therapeutic strategy in the management of significant coronary stenosis in patients undergoing TAVI.

In this prospective, multicenter study, we sought to evaluate the impact of CAD on clinical outcomes in a large cohort of patients who underwent TAVI with the 18-Fr CRS device.

Section snippets

Methods

Consecutive patients (N = 663) undergoing TAVI with the 3rd generation 18-Fr CRS between June 2007 through December 2009 at 14 centers across Italy were prospectively enrolled in a dedicated web-based database. All patients met the eligibility criteria for intervention proposed by the Task Force on the management of valvular heart disease of the European Society of Cardiology [5]. For each individual patient, contraindication to conventional AVR was established based on a consensus of a local

Study population

All patients who underwent TAVI (N = 663) were eligible for inclusion. Four patients were excluded from analysis due to failure to successfully release the prosthesis inside the native aortic valve. Thus the study population comprised of 659 patients who underwent a successful TAVI procedure. The study cohort was segregated into two groups based on the presence or absence of historical CAD as defined by previous percutaneous (28.5%) and surgical (15.8%) revascularization (CAD group and no-CAD

Discussion

The main finding of this study, besides confirming the high prevalence of CAD in elderly patients with severe AS (38%), is that acute and mid-term outcomes of patients who underwent TAVI with CRS device were not affected by the presence of concomitant CAD as defined by previous CABG or PCI. Specifically, the procedures were not complicated by events directly related to the presence of concomitant CAD. At 30-days, our results did not show a significant difference in terms of survival among

Study limitations

The present study has several important limitations: first, since our data is entered prospectively into a web database before the introduction of VARC definitions, re-evaluation of clinical source documents relating to clinical events as they classified according to the VARC criteria may result in the underestimation of the true frequency of some events; second, the lack of specific tools such as fractional flow reserve, intravascular ultrasound, quantitative coronary analysis or myocardial

Conclusions

The present multicenter registry showed that coexisting coronary artery disease, as defined by previous CABG or PCI, does not impact procedural outcomes and mid-term incidence of MACCE and survival in elderly patients undergoing TAVI with CRS prosthesis.

Disclosures

Disclosure: Gian Paolo Ussia, Anna Sonia Petronio, Federica Ettori, Angelo Ramondo, Gennaro Santoro and Francesco Bedogni are proctor physicians for Medtronic Incorporation; all other authors have not conflicts of interests to declare.

Acknowledgment

We would like to acknowledge the members of the CoreValve Italian Registry without whose work this paper could not have been written. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

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Evolving Paradigms in Transcatheter Aortic Valve Replacement: Results from a High-Volume, Single Center Experience
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Given the expanding indications toward younger patients at lower surgical risk, transcatheter aortic valve replacement (TAVR) simplification and streamlining are gaining increasing importance. Patients who underwent TAVR from the year 2015 to 2020 were prospectively enrolled. The patients were divided in time tertiles according to the date of intervention. Data on preprocedural planning, including coronary computed tomography angiography (CCTA), procedures, and outcomes, were compared between the time tertiles. A total of 771 consecutive patients from a single institution were enrolled. We observed a trend toward the use of a fully percutaneous versus surgical approach for the index access, left radial artery versus contralateral femoral artery for the secondary access, and left ventricular pacing on the stiff guidewire versus right ventricular pacing. Immediate device success significantly increased, whereas the length of hospital stay decreased. Overall, approximately 60% of the total study population underwent CCTA instead of coronary angiography, with no adverse events. One-year survival rates significantly improved over time. A simplified TAVR approach was associated with better survival, whereas low baseline functional capacity, preexisting coronary artery disease, renal impairment, periprocedural blood transfusions, and paravalvular leak were related to worse outcomes. In conclusion, our study showed a constant tendency to procedure streamlining and improve procedural success and 1-year outcomes. A strategy based on CCTA allows sparing safely almost half of the preoperative invasive coronary angiography.
Aortic Stenosis and Coronary Artery Disease: Cost of Transcatheter vs Surgical Management
2022, Annals of Thoracic Surgery
Surgical aortic valve replacement with coronary artery bypass grafting (SAVR+CABG) is the recommended treatment for aortic stenosis and coronary artery disease; however, percutaneous coronary intervention at the time of transcatheter aortic valve replacement (TAVR+PCI) is used with increasing frequency.
Using the National Inpatient Sample, we identified all adult admissions with a diagnosis of aortic stenosis. Subgroups of SAVR+CABG and TAVR+PCI formed the study group. Outcomes of interest included total hospitalization charges, temporal trends, in-hospital mortality, and complications.
Between 2012 and 2017, a total of 97 955 admissions (95.9%) received SAVR+CABG, and 4240 (4.1%) received TAVR+PCI; the proportion of TAVR+PCI increased from 1% in 2012 to 9.2% in 2017 (P < .001). Compared with patients receiving TAVR+PCI, admissions receiving SAVR+CABG were younger, more likely to be male, and had lower comorbidity (all P < .001). Adjusted in-hospital mortality was comparable in both groups (odds ratio 0.94; 95% confidence interval, 0.79 to 1.11; P = .45). Higher rates of pacemaker implantation, cardiac arrest, and vascular complications were seen in the TAVR+PCI group, whereas SAVR+CABG was associated with a greater requirement for prolonged ventilation. Admissions receiving TAVR+PCI had shorter lengths of hospital stay and were more likely to be discharged home. Nevertheless, the TAVR+PCI group had higher hospitalization charges compared with the SAVR+CABG group (all P < .001).
There has been a steady increase in the use of percutaneous strategies for aortic stenosis and coronary artery disease management. In-hospital mortality was comparable in SAVR+CABG and TAVR+PCI groups, but despite shorter in-hospital stays, TAVR+PCI was associated with higher cardiac and vascular complication rates and hospitalization charges.
Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis
2021, JACC: Cardiovascular Interventions
Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist, with up to two thirds of patients with AS having significant CAD. Given the challenges when both disease states are present, these patients require a tailored approach diagnostically and therapeutically. In this review the authors address the impact of AS and aortic valve replacement (AVR) on coronary hemodynamic status and discuss the assessment of CAD and the role of revascularization in patients with concomitant AS and CAD. Remodeling in AS increases the susceptibility of myocardial ischemia, which can be compounded by concomitant CAD. AVR can improve coronary hemodynamic status and reduce ischemia. Assessment of the significance of coexisting CAD can be done using noninvasive and invasive metrics. Revascularization in patients undergoing AVR can benefit certain patients in whom CAD is either prognostically or symptomatically important. Identifying this cohort of patients is challenging and as yet incomplete. Patients with dual pathology present a diagnostic and therapeutic challenge; both AS and CAD affect coronary hemodynamic status, they provoke similar symptoms, and their respective treatments can have an impact on both diseases. Decisions regarding coronary revascularization should be based on understanding this complex relationship, using appropriate coronary assessment and consensus within a multidisciplinary team.
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.
Angiographic Functional Scoring of Coronary Artery Disease Predicts Mortality in Patients With Severe Aortic Stenosis Undergoing TAVR
2020, Cardiovascular Revascularization Medicine
Citation Excerpt :
It is therefore of widespread interest whether these same principles should be extrapolated to patients undergoing transcatheter therapies. The influence of CAD on TAVR outcomes has previously been explored in large registries with conflicting results [3–6]. Given the heterogenous nature of CAD, angiographic complexity using SYNTAX scoring (SS) was explored as an alternative means to stratify outcomes [7–10].
Coronary artery disease (CAD) is common in patients undergoing transcatheter aortic valve replacement (TAVR), although its prognostic significance is questionable. Significant CAD stratified using SYNTAX score (SS) has been associated with greater mortality, yet it is unknown whether the functional impact of CAD also impacts outcomes in this cohort. DILEMMA score (DS) is a validated angiographic functional scoring tool that correlates with fractional flow reserve and instantaneous wave-free ratio.
This study sought to assess the functional impact of CAD on outcomes in patients undergoing TAVR for severe aortic stenosis (AS).
229 patients were included in this analysis. Patients underwent angiographic DS and SS and were classified using predefined values. The primary endpoint was one-year all-cause mortality, with secondary endpoints of 30-day major adverse cardiac and cerebrovascular events (MACCE).
The mean age was 83.9 ± 0.5 years (55.0% female), with 11.8% all-cause mortality. CAD defined by ≥30% stenosis in any vessel was not associated with adverse outcomes (HR = 1.08, p = 0.84). However, the risk of one-year mortality was greater in patients with either SS > 9 (20.8% vs. 9.4%, HR 2.34, p = 0.03) or DS > 2 (18.4% vs. 8.5%, HR = 2.28, p = 0.03). Both scoring systems were also associated with 30-day MACCE (both p < 0.05). After multivariate adjustment, independent predictors of one-year mortality were DS > 2 (HR = 2.29, p = 0.04), left ventricular ejection fraction <50% (HR 2.66, p = 0.04) and COPD (HR 2.43, p = 0.04).
Our results demonstrate that angiographic functional scoring is independently predictive of both 12-month mortality and 30-day MACCE following TAVR.
Aortic Stenosis and Noncardiac Surgery in the Era of Transcatheter Aortic Valve Replacement
2020, Journal of Cardiothoracic and Vascular Anesthesia
Aortic stenosis (AS) is the most common form of valvular heart disease in the elderly. As this patient population continues to increase, anesthesiologists more often will encounter these patients in the perioperative setting for noncardiac surgical procedures. Cardiac risk during noncardiac surgery in the patient with AS appears to have decreased significantly compared with previous reports that shaped current practice guidelines for perioperative management. In addition, these guidelines preceded the publication of current data supporting the continually expanding role for transcatheter aortic valve replacement in the treatment of AS. In this review, the authors highlight the most recent evidence suggesting that an update of these guidelines is warranted. In addition, the accumulating evidence supporting the role for transcatheter aortic valve replacement to treat AS since the publication of guidelines is reviewed.

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Impact of coronary artery disease in elderly patients undergoing transcatheter aortic valve implantation: Insight from the Italian CoreValve Registry

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Study population

Discussion

Study limitations

Conclusions

Disclosures

Acknowledgment

Am J Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Catheter Cardiovasc Interv

Angina, coronary risk factors and coronary artery disease in patients with valvular disease. A prospective study

Eur Heart J

Aortic valve replacement in the elderly. Effect of gender and coronary artery disease on operative mortality

Circulation

Predictors of mortality, complications, and length of stay in aortic valve replacement for aortic stenosis

Circulation

Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology; ESC Committee for Practice Guidelines. Guidelines on the management of valvular heart disease: the Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology

Eur Heart J

Preoperative identification of patients likely to have left ventricular dysfunction after aortic valve replacement. Participants in the Veterans Administration Cooperative Study on Valvular Heart Disease

Circulation