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Late Outcomes of PCI in the Workup Pre-TAVR
Quick Takes
- Patients undergoing PCI prior to TAVR often have multivessel disease with complex lesion characteristics.
- After 2-year follow-up, rates of target lesion (2.7%) and vessel failure (3.3) were low; however, nearly a third of the cohort died (death 28.7%; CV death 8.8%).
- Management of concomitant CAD among patients undergoing TAVR remains unclear and warrants further study.
Study Questions:
What are clinical characteristics, and periprocedural and long-term clinical outcomes among patients undergoing percutaneous coronary intervention (PCI) prior to transcatheter aortic valve replacement (TAVR)?
Methods:
This multicenter study included 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 patients exhibited a multivessel disease and the mean SYNTAX (SYNergy between PCI with TAXUS and Cardiac Surgery) score was 12.1 ± 9.1. The lesions were of B2/C type, calcified, bifurcation, and ostial in 49.9%, 45.8%, 21.4%, and 19.3% of cases, respectively. After a median follow-up of 2 (interquartile range, 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 (2.7%) patients. 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, respectively, 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 and 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:
This is a single-arm, retrospective analysis of patients undergoing PCI prior to TAVR. In this older cohort of patients (mean age 81 years), target vessel and lesion failure rates were low, but there was approximately 30% all-cause mortality after 2 years. Presence of complex coronary artery disease (CAD) (higher SYNTAX score) did not increase risk of cardiovascular events. Findings add to our understanding of CAD among patients undergoing TAVR; however, the approach to management of incidental CAD found during TAVR workup remains unclear and warrants further study.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, 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, Geriatrics, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Peripheral Arterial Disease, Pulmonary Disease, Chronic Obstructive, Risk Factors, Secondary Prevention, Stroke, Transcatheter Aortic Valve Replacement, Vascular Diseases
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