An 84-year-old female patient presents with progressive worsening of dyspnea on exertion and occasional episodes of lightheadedness. The patient reports that over the last 12 months, her symptoms have progressively worsened, and she is now able to walk only around the house. Her past medical history is significant for long-standing hypertension, chronic kidney disease (stage II), anemia of chronic disease, and transient ischemic attack (TIA). On examination, the patient is a thin, frail woman in no apparent distress at rest. Auscultation reveals a late-peaking ejection systolic murmur. An electrocardiogram shows evidence of left ventricular hypertrophy. An echocardiogram reveals normal left ventricular systolic function, severe degenerative aortic stenosis (AS), mean transvalvular gradient of 48 mm Hg, and calculated aortic valve area of 0.7 cm2. Dense calcification of the ascending aorta is noted on computed tomography scan (porcelain aorta). The patient undergoes coronary angiography; pertinent findings are shown here.
A heart team discussion was held, and the patient was deemed high risk for surgical aortic valve replacement (SAVR) due to overall frailty, severe calcification of ascending aorta, and prior TIA.
What is the next step in management of this patient?
Show Answer
The correct answer is: B. Percutaneous coronary intervention (PCI) prior to TAVR
TAVR has emerged as standard treatment for patients with severe degenerative AS who are deemed high risk for conventional surgery.1 Because degenerative AS and coronary artery disease (CAD) share similar risk factor profiles, significant CAD is fairly prevalent in patients undergoing TAVR, with reported prevalence ranging from 25-50% in different series.2 The presence of CAD is associated with poor procedural outcomes and long-term survival. Patients with CAD are about 10 times more likely to die within 30 days of the TAVR procedure compared with a patient with no significant CAD.3 A greater severity of CAD (high SYNTAX score) is associated with worse prognosis. Unrevascularized CAD remains largely understudied because patients with significant CAD were excluded from major trials. However, multiple retrospective studies showed that revascularization attenuates the effect of CAD on outcomes.4 Many patients with severe AS and CAD don't present with angina. Rapp et al. showed that angina is a poor predictor of the presence of CAD in patients with AS: sensitivity of 68%, specificity of 46%, positive predictive value of 43%, and negative predictive value of 71%.5 Severe AS makes ischemia testing very complicated because exercise stress testing and high dose dobutamine testing are relatively contraindicated, and vasodilatory testing is not well validated in this group of patients.
In patients deemed high risk for SAVR, the addition of CABG makes procedural and in-hospital mortality even higher. PCI should be considered for severe coronary stenoses in proximal epicardial coronary vessels with a large area of myocardium at risk. There is limited experience in this area, but PCI can be safely performed in patients with severe AS without an increased risk of short-term adverse outcomes. Timing of PCI is also understudied, but a short delay after PCI is preferred.2
The ongoing ACTIVATION (The percutaneous coronary intervention prior to transcatheter aortic valve implantation) trial is testing the hypothesis of pre-TAVR PCI versus no PCI in a randomized control trial, the results of which would help answer this question.
References
Kodali SK, Williams MR, Smith CR, et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med 2012;366:1686-95.
Goel SS, Ige M, Tuzcu EM, et al. Severe aortic stenosis and coronary artery disease--implications for management in the transcatheter aortic valve replacement era: a comprehensive review. J Am Coll Cardiol 2013;62:1-10.
Dewey TM, Brown DL, Herbert MA, et al. Effect of concomitant coronary artery disease on procedural and late outcomes of transcatheter aortic valve implantation. Ann Thorac Surg 2010;89:758-67.
Witberg G, Lavi I, Harari E, et al. Effect of coronary artery disease severity and revascularization completeness on 2-year clinical outcomes in patients undergoing transcatether aortic valve replacement. Coron Artery Dis 2015;26:573-82.
Rapp AH, Hillis LD, Lange RA, Cigarroa JE. Prevalence of coronary artery disease in patients with aortic stenosis with and without angina pectoris. Am J Cardiol 2001;87:1216-7.
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