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Outcomes of PCI in the Workup Pre-TAVR
Quick Takes
- Patients undergoing PCI pre-TAVR have complex coronary artery disease.
- There were low rates of target lesion failure but high rates of MACCE on 2-year follow-up among patients undergoing pre-TAVR PCI.
- Questions regarding which patients and lesions benefit from pre-TAVR revascularization remain unanswered.
Study Questions:
What are clinical characteristics, angiographic features, and long-term outcomes among patients undergoing percutaneous coronary intervention (PCI) during transcatheter aortic valve replacement (TAVR) workup?
Methods:
This was a multicenter study including 1,197 consecutive patients who had PCI in the workup pre-TAVR. A total of 1,705 lesions (1.5 ± 0.7 lesions per patient) were included. Death, stroke, myocardial infarction, and major adverse cardiovascular and cerebrovascular events (MACCE) were recorded, as well as target lesion failure (TLF) and target vessel failure (TVF).
Results:
One half of the patients exhibited multivessel disease and the mean SYNTAX score was 12.1 ± 9.1. The lesions were of B2/C type, calcified, and bifurcation in 49.9%, 45.8%, and 21.4% of cases, respectively. After a median follow-up of 2 (1-3) years, a total of 444 (37.1%) patients presented with a MACCE. Forty patients exhibited TVF (3.3%), with TLF identified in 32 patients (2.7%). By multivariable analysis, previous peripheral artery disease (p < 0.001), chronic obstructive pulmonary disease (p = 0.002), atrial fibrillation (p = 0.003), diabetes mellitus (p = 0.012), and incomplete revascularization (p = 0.014) determined an increased risk of MACCE. In patients with unprotected left main or SYNTAX score >32 (n = 128), TLF, TVF, and MACCE rates were 3.9%, 6.3%, and 35.9%, respectively (p = 0.378, p = 0.065, and p = 0.847 vs. the rest of the population).
Conclusions:
Patients undergoing PCI in the workup pre-TAVR frequently exhibited complex coronary lesions and multivessel disease. PCI was successful in most cases, and TLF/TVF rates at 2-year follow-up were low, also among patients with high-risk coronary features. However, overall MACCE occurred in about one third of patients, with incomplete revascularization determining an increased risk. These results should inform future studies to better determine the optimal revascularization strategy pre-TAVR.
Perspective:
Identifying patients and lesions which benefit from PCI prior to TAVR remains debated. The current study highlights clinical and angiographic characteristics of patients undergoing PCI pre-TAVR. As expected, complex coronary artery disease with high likelihood of calcified and bifurcation disease was noted. Overall rates of stent thrombosis or restenosis were low; however, MACCE rates were high for this older, intermediate- to high-risk TAVR cohort. Incomplete revascularization was a predictor of MACCE in follow-up. Questions regarding which patients and lesion benefit from pre-TAVR revascularization remain unanswered.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine
Keywords: Atrial Fibrillation, Coronary Artery Disease, Diabetes Mellitus, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Peripheral Arterial Disease, Pulmonary Disease, Chronic Obstructive, Stents, Stroke, Thrombosis, Transcatheter Aortic Valve Replacement, Transcatheter Cardiovascular Therapeutics, TCT20, Vascular Diseases
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