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  • Review Article
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Assessment, treatment, and prognostic implications of CAD in patients undergoing TAVI

Nature Reviews Cardiology volume 13, pages 276–285 (2016)Cite this article

Subjects

Key Points

  • The true incidence of obstructive coronary artery disease (CAD) among patients undergoing transcatheter aortic valve implantation (TAVI) is not known

  • Assessment of CAD using angiography only can overestimate the presence of myocardial ischaemia in patients before TAVI

  • Anatomical scoring criteria for CAD can improve the selection of high-risk patients undergoing TAVI

  • Coronary pressure-wire measurements using conventional algorithms before TAVI might underestimate myocardial ischaemia

  • Noninvasive stress testing can be used safely in patients before TAVI, but might overestimate myocardial ischaemia

  • Percutaneous coronary intervention after TAVI is still not widely practised, and only case reports are available

Abstract

Coronary artery disease (CAD) is common in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), but its clinical relevance is controversial. At present, the optimal means of defining CAD in patients undergoing TAVI with respect to its prognostic implications and the assessment of myocardial ischaemia is not known. For this reason, the best treatment options are a matter for debate, and current guidelines do not recommend revascularization. As the indications for TAVI expand, the lack of any rigorous means of guiding coronary revascularization might negatively affect the clinical outcomes of future patients. In this Review, we summarize the methods of assessing CAD in TAVI populations, and the data on the safety and efficacy of percutaneous coronary intervention in patients undergoing TAVI. We discuss the putative effects of aortic stenosis on the functional assessment of CAD using pressure or flow wires or by noninvasive stress testing. We propose that a new, well-validated method of assessing CAD as a cause of myocardial ischaemia — which distinguishes it from myocardial infarction, previous revascularization, or non-flow-limiting disease — in patients with severe aortic stenosis is needed to guide revascularization in the current era of TAVI.

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Figure 1: Putative factors that might influence coronary pressure or flow measurements in the presence of severe aortic stenosis in patients undergoing TAVI.
Figure 2: Representative coronary pressure and flow traces throughout the cardiac cycle before and after TAVI46,49,50.

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References

  1. Stefanini, G. G., Stortecky, S., Wenaweser, P. & Windecker, S. Coronary artery disease in patients undergoing TAVI: why, what, when and how to treat. EuroIntervention 10, U69–U75 (2014).

    Article  Google Scholar 

  2. Khawaja, M. Z., Redwood, S. R. & Thomas, M. Coronary artery disease in patients undergoing TAVI — why not to treat. EuroIntervention 10, U76–U83 (2014).

    Article  Google Scholar 

  3. Julius, B. K. et al. Angina pectoris in patients with aortic stenosis and normal coronary arteries: mechanisms and pathophysiological concepts. Circulation 95, 892–898 (1997).

    Article  CAS  Google Scholar 

  4. Masson, J. B. et al. Impact of coronary artery disease on outcomes after transcatheter aortic valve implantation. Catheter. Cardiovasc. Interv. 76, 165–173 (2010).

    Article  Google Scholar 

  5. Stefanini, G. G. et al. Coronary artery disease severity and aortic stenosis: clinical outcomes according to SYNTAX score in patients undergoing transcatheter aortic valve implantation Eur. Heart J. 35, 2530–2540 (2014).

    Article  Google Scholar 

  6. Khawaja, M. Z. et al. The effect of coronary artery disease defined by quantitative coronary angiography and SYNTAX score upon outcome after transcatheter aortic valve implantation (TAVI) using the Edwards bioprosthesis. EuroIntervention 11, 450–455 (2015).

    Article  Google Scholar 

  7. Van Mieghem, N. M. et al. Complete revascularization is not a prerequisite for success in current transcatheter aortic valve implantation practice. JACC Cardiovasc. Interv. 6, 867–875 (2013).

    Article  Google Scholar 

  8. Leon, M. B. et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N. Engl. J. Med. 363, 1597–1607 (2010).

    Article  CAS  Google Scholar 

  9. Smith, C. R. et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N. Engl. J. Med. 364, 2187–2198 (2011).

    Article  CAS  Google Scholar 

  10. Chieffo, A. et al. Transcatheter aortic valve implantation with the Edwards SAPIEN versus the Medtronic CoreValve Revalving system devices: a multicenter collaborative study: the PRAGMATIC Plus Initiative (Pooled-RotterdAm-Milano-Toulouse In Collaboration). J. Am. Coll. Cardiol. 61, 830–836 (2013).

    Article  Google Scholar 

  11. Abdel-Wahab, M. et al. Balloon-expandable versus self-expandable valves in patients undergoing transcatheter aortic valve replacement: the CHOICE randomized clinical trial. JAMA 311, 1503–1514 (2014).

    Article  Google Scholar 

  12. Duncan, A. et al. Long-term outcomes after transcatheter aortic valve replacement in high-risk patients with severe aortic stenosis: the UK Transcatheter Aortic Valve Implantation Registry. JACC Cardiovasc. Interv. 8, 645–653 (2015).

    Article  Google Scholar 

  13. Thielmann, M. et al. Prognostic value of preoperative cardiac troponin I in patients with non-ST-segment elevation acute coronary syndromes undergoing coronary artery bypass surgery. Chest 128, 3526–3536 (2005).

    Article  CAS  Google Scholar 

  14. Etchells, E., Meade, M., Tomlinson, G. & Cook, D. Semi-quantitative dipyridamole myocardial stress perfusion imaging for cardiac risk assessment before noncardiac vascular surgery: a metaanalysis. J. Vasc. Surg. 36, 534–540 (2002).

    Article  Google Scholar 

  15. Beach, J. M. et al. Coronary artery disease and outcomes of aortic valve replacement for severe aortic stenosis. J. Am. Coll. Cardiol. 61, 837–848 (2013).

    Article  Google Scholar 

  16. Mullany, C. J. et al. Coronary artery disease and its management: influence on survival in patients undergoing aortic valve replacement. J. Am. Coll. Cardiol. 10, 66–72 (1987).

    Article  CAS  Google Scholar 

  17. Lund, O., Nielsen, T. T., Pilegaard, H. K., Magnussen, K. & Knudsen, M. A. The influence of coronary artery disease and bypass grafting on early and late survival after valve replacement for aortic stenosis. J. Thorac. Cardiovasc. Surg. 100, 327–337 (1990).

    CAS  PubMed  Google Scholar 

  18. Tjang, Y. S., van Hees, Y., Korfer, R., Grobbee, D. E. & van der Heijden, G. J. Predictors of mortality after aortic valve replacement. Eur. J. Cardiothorac. Surg. 32, 469–474 (2007).

    Article  Google Scholar 

  19. Likosky, D. S. et al. Long-term survival of the very elderly undergoing aortic valve surgery. Circulation 120, S127–S133 (2009).

    Article  Google Scholar 

  20. Iung, B. et al. Prognosis of valve replacement for aortic stenosis with or without coexisting coronary heart disease: a comparative study. J. Heart Valve Dis. 2, 430–439 (1993).

    CAS  PubMed  Google Scholar 

  21. Svensson, L. G., Blackstone, E. H. & Cosgrove, D. M. 3rd Surgical options in young adults with aortic valve disease. Curr. Probl. Cardiol. 28, 417–480 (2003).

    Article  Google Scholar 

  22. Dewey, T. M. et al. Effect of concomitant coronary artery disease on procedural and late outcomes of transcatheter aortic valve implantation. Ann. Thorac. Surg. 89, 758–767 (2010).

    Article  Google Scholar 

  23. Greason, K. L. et al. Transcatheter versus surgical aortic valve replacement in patients with prior coronary artery bypass graft operation: a PARTNER trial subgroup analysis. Ann. Thorac. Surg. 98, 1–7 (2014).

    Article  Google Scholar 

  24. Gilard, M. et al. Registry of transcatheter aortic-valve implantation in high-risk patients. N. Engl. J. Med. 366, 1705–1715 (2012).

    Article  CAS  Google Scholar 

  25. Gautier, M. et al. Impact of coronary artery disease on indications for transcatheter aortic valve implantation and on procedural outcomes. EuroIntervention 7, 549–555 (2011).

    Article  Google Scholar 

  26. Ludman, P. F. et al. Transcatheter aortic valve implantation in the United Kingdom: temporal trends, predictors of outcome, and 6-year follow-up: a report from the UK Transcatheter Aortic Valve Implantation (TAVI) Registry, 2007 to 2012. Circulation 131, 1181–1190 (2015).

    Article  Google Scholar 

  27. Schymik, G. et al. European experience with the second-deneration Edwards SAPIEN XT transcatheter heart valve in patients with severe aortic stenosis: 1-year outcomes from the SOURCE XT Registry. JACC Cardiovasc. Interv. 8, 657–669 (2015).

    Article  Google Scholar 

  28. Thomas, M. et al. Thirty-day results of the SAPIEN aortic Bioprosthesis European Outcome (SOURCE) Registry: a European registry of transcatheter aortic valve implantation using the Edwards SAPIEN valve. Circulation 122, 62–69 (2010).

    Article  Google Scholar 

  29. Linke, A. et al. Treatment of aortic stenosis with a selfexpanding transcatheter valve: the International Multi-centre ADVANCE Study. Eur. Heart J. 35, 2672–2684 (2014).

    Article  Google Scholar 

  30. Abdel-Wahab, M. et al. Comparison of outcomes in patients having isolated transcatheter aortic valve implantation versus combined with preprocedural percutaneous coronary intervention. Am. J. Cardiol. 109, 581–586 (2012).

    Article  Google Scholar 

  31. Pasic, M. et al. Combined elective percutaneous coronary intervention and transapical transcatheter aortic valve implantation. Interact. Cardiovasc. Thorac. Surg. 14, 463–468 (2012).

    Article  Google Scholar 

  32. Gasparetto, V. et al. Safety and effectiveness of a selective strategy for coronary artery revascularization before transcatheter aortic valve implantation. Catheter. Cardiovasc. Interv. 81, 376–383 (2013).

    Article  Google Scholar 

  33. Abramowitz, Y. et al. Comparison of early and late outcomes of TAVI alone compared to TAVI plus PCI in aortic stenosis patients with and without coronary artery disease. Catheter. Cardiovasc. Interv. 83, 649–654 (2014).

    Article  Google Scholar 

  34. Griese, D. P. et al. Concomitant coronary intervention is associated with poorer early and late clinical outcomes in selected elderly patients receiving transcatheter aortic valve implantation. Eur. J. Cardiothorac. Surg. 46, e1–e7 (2014).

    Article  Google Scholar 

  35. Van Gameren, M. et al. Do we need separate risk stratification models for hospital mortality after heart valve surgery? Ann. Thorac. Surg. 85, 921–930 (2008).

    Article  Google Scholar 

  36. Pijls, N. H. et al. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER study. J. Am. Coll. Cardiol. 49, 2105–2111 (2007).

    Article  Google Scholar 

  37. Tonino, P. A. et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N. Engl. J. Med. 360, 213–224 (2009).

    Article  CAS  Google Scholar 

  38. Prati, F. et al. Angiography alone versus angiography plus optical coherence tomography to guide decision-making during percutaneous coronary intervention: the Centro per la Lotta contro l'Infarto-Optimisation of Percutaneous Coronary Intervention (CLI-OPCI) study. EuroIntervention 8, 823–829 (2012).

    Article  Google Scholar 

  39. Tu, S. et al. In vivo comparison of arterial lumen dimensions assessed by co-registered three-dimensional (3D) quantitative coronary angiography, intravascular ultrasound and optical coherence tomography. Int. J. Cardiovasc. Imaging 28, 1315–1327 (2012).

    Article  Google Scholar 

  40. Villari, B. et al. Regression of coronary artery dimensions after successful aortic valve replacement. Circulation 85, 972–978 (1992).

    Article  CAS  Google Scholar 

  41. O'Sullivan, C. J. et al. Clinical outcomes and revascularization strategies in patients with low-flow, low-gradient severe aortic valve stenosis according to the assigned treatment modality. JACC Cardiovasc. Interv. 8, 704–717 (2015).

    Article  Google Scholar 

  42. Khawaja, M. Z., Wang, D., Pocock, S., Redwood, S. R. & Thomas, M. R. The percutaneous coronary intervention prior to transcatheter aortic valve implantation (ACTIVATION) trial: study protocol for a randomized controlled trial. Trials 15, 300 (2014).

    Article  Google Scholar 

  43. Takashima, H. et al. Severity of morphological lesion complexity affects fractional flow reserve in intermediate coronary stenosis. J. Cardiol. 66, 239–245 (2015).

    Article  Google Scholar 

  44. De Bruyne, B. et al. Fractional flow reserve-guided PCI for stable coronary artery disease. N. Engl. J. Med. 371, 1208–1217 (2014).

    Article  CAS  Google Scholar 

  45. Rajappan, K. et al. Mechanisms of coronary microcirculatory dysfunction in patients with aortic stenosis and angiographically normal coronary arteries. Circulation 105, 470–476 (2002).

    Article  Google Scholar 

  46. Dixon, J. A. & Spinale, F. G. Myocardial remodelling: cellular and extracellular events and targets. Annu. Rev. Physiol. 73, 47–68 (2011).

    Article  CAS  Google Scholar 

  47. Choudhury, L. et al. Coronary vasodilator reserve in primary and secondary left ventricular hypertrophy: a study with positron emission tomography. Eur. Heart J. 18, 108–116 (1997).

    Article  CAS  Google Scholar 

  48. Heusch, G. Alpha-adrenergic coronary vasoconstriction in humans. J. Am. Coll. Cardiol. 55, 1278 (2010).

    Article  Google Scholar 

  49. Broyd, C. J. et al. Myocardial ischemia in aortic stenosis: insights from arterial pulse-wave dynamics after percutaneous aortic valve replacement. Trends Cardiovasc. Med. 23, 185–191 (2013).

    Article  Google Scholar 

  50. Galiuto, L. et al. Impaired coronary and myocardial flow in severe aortic stenosis is associated with increased apoptosis: a transthoracic Doppler and myocardial contrast echocardiography study. Heart 92, 208–212 (2006).

    Article  CAS  Google Scholar 

  51. Davies, J. E. et al. Arterial pulse wave dynamics after percutaneous aortic valve replacement: fall in coronary diastolic suction with increasing heart rate as a basis for angina symptoms in aortic stenosis. Circulation 124, 1565–1572 (2011).

    Article  Google Scholar 

  52. Stähli, B. E., Maier, W., Corti, R., Lüscher, T. F. & Altwegg, L. A. Fractional flow reserve evaluation in patients considered for transfemoral transcatheter aortic valve implantation: a case series. Cardiology 123, 234–239 (2012).

    Article  Google Scholar 

  53. Nijjer, S. S. et al. Improvement in coronary haemodynamics after percutaneous coronary intervention: assessment using instantaneous wave-free ratio. Heart 99, 1740–1748 (2013).

    Article  Google Scholar 

  54. Sen, S. et al. Development and validation of a new adenosine-independent index of stenosis severity from coronary wave-intensity analysis: results of the ADVISE (ADenosine Vasodilator Independent Stenosis Evaluation) study. J. Am. Coll. Cardiol. 59, 1392–1402 (2012).

    Article  CAS  Google Scholar 

  55. Wiegerinck, E. M. et al. Impact of aortic valve stenosis on coronary hemodynamics and the instantaneous effect of transcatheter aortic valve implantation. Circ. Cardiovasc. Interv. 8, e002443 (2015).

    Article  Google Scholar 

  56. Davies, J. E. et al. Evidence of a dominant backward-propagating 'suction' wave responsible for diastolic coronary filling in humans, attenuated in left ventricular hypertrophy. Circulation 113, 1768–1778 (2006).

    Article  Google Scholar 

  57. Bountioukos, M. et al. Safety of dobutamine stress echocardiography in patients with aortic stenosis. J. Heart Valve Dis. 12, 441–446 (2003).

    PubMed  Google Scholar 

  58. Baroni, M. et al. Mechanisms of regional ischaemic changes during dipyridamole echocardiography in patients with severe aortic valve stenosis and normal coronary arteries. Heart 75, 492–497 (1996).

    Article  CAS  Google Scholar 

  59. Zajarias, A., Eltchaninoff, H. & Cribier, A. Successful coronary intervention after percutaneous aortic valve replacement. Catheter. Cardiovasc. Interv. 69, 522–524 (2007).

    Article  Google Scholar 

  60. Greenberg, G. & Kornowski, R. Coronary angioplasty after self-expandable transcatheter aortic valve implantation. J. Invasive Cardiol. 25, 361–363 (2013).

    PubMed  Google Scholar 

  61. Ribeiro, H. B. et al. Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry. J. Am. Coll. Cardiol. 62, 1552–1562 (2013).

    Article  Google Scholar 

  62. Mohr, F. W. et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 381, 629–638 (2013).

    Article  Google Scholar 

  63. Adams, D. H. et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N. Engl. J. Med. 370, 1790–1798 (2014).

    Article  CAS  Google Scholar 

  64. Babaliaros, V. et al. 30 day outcomes from the PARTNER II trial for transapical and transfemoral 29mm TAVR in inoperable patients with the Edwards Sapien XT [abstract]. J. Am. Coll. Cardiol. 63, A1687 (2014).

    Article  Google Scholar 

  65. Mack, M. J. et al. 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet 385, 2477–2484 (2015).

    Article  Google Scholar 

  66. Kapadia, S. R. et al. 5-year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet 385, 2485–2491 (2015).

    Article  Google Scholar 

  67. Reardon, M. J. et al. 2-year outcomes in patients undergoing surgical or self-expanding transcatheter aortic valve replacement. J. Am. Coll. Cardiol. 66, 113–121 (2015).

    Article  Google Scholar 

  68. Penkalla, A. et al. Transcatheter aortic valve implantation combined with elective coronary artery stenting: a simultaneous approach Eur. J. Cardiothorac. Surg. 47, 1083–1089 (2015).

    Article  Google Scholar 

  69. Cremer, P. C. et al. Stress positron emission tomography is safe and can guide coronary revascularization in high-risk patients being considered for transcatheter aortic valve replacement. J. Nucl. Cardiol. 21, 1001–1010 (2014).

    Article  Google Scholar 

  70. Burgstahler, C. et al. Adenosine stress first pass perfusion for the detection of coronary artery disease in patients with aortic stenosis: a feasibility study. Int. J. Cardiovasc. Imaging 24, 195–200 (2008).

    Article  Google Scholar 

  71. Patsilinakos, S. P. et al. Adenosine stress myocardial perfusion tomographic imaging in patients with significant aortic stenosis. J. Nucl. Cardiol. 11, 20–25 (2004).

    Article  Google Scholar 

  72. Demirkol, M. O., Yaymaci, B., Debeş, H., Başaran, Y. & Turan, F. Dipyridamole myocardial perfusion tomography in patients with severe aortic stenosis. Cardiology 97, 37–42 (2002).

    Article  CAS  Google Scholar 

  73. Patsilinakos, S. P. et al. Detection of coronary artery disease in patients with severe aortic stenosis with noninvasive methods. Angiology 50, 309–317 (1999).

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, Tooting, UK

    Edward Danson

  2. Royal North Shore Hospital, Reserve Road, St Leonard's, 2065, New South Wales, Australia

    Peter Hansen & Ravinay Bhindi

  3. National Heart and Lung Institute, Imperial College London, Dovehouse Street, London, SW3 6LY, UK

    Sayan Sen & Justin Davies

  4. Monash Cardiovascular Research Centre, Monash University, Clayton, 3168, Victoria, Australia

    Ian Meredith

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E.D., P.H., and R.B. researched data for the article and wrote the manuscript. All the authors contributed substantially to discussion of content, and reviewing and editing the manuscript before submission.

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Correspondence to Edward Danson.

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I.M. receives consulting fees from Boston Scientific. The other authors declare no competing interests.

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Danson, E., Hansen, P., Sen, S. et al. Assessment, treatment, and prognostic implications of CAD in patients undergoing TAVI. Nat Rev Cardiol 13, 276–285 (2016). https://doi.org/10.1038/nrcardio.2016.9

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