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Are Concurrent TAVR and LM PCI Safe and Feasible?
Study Questions:
What are clinical outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) plus left main (LM) percutaneous coronary intervention (PCI)?
Methods:
The TAVR-LM registry was a retrospective international registry of 204 consecutive patients undergoing TAVR plus LM-PCI from January 2007 to December 2014. The authors generated 128 matched patient pairs by performing 1:1 case-control matching between 167 patients with pre-existing LM stents undergoing TAVR and 1,888 control patients undergoing TAVR without LM revascularization. Patients were divided into three groups: planned LM PCI (performed prior to or during TAVR), unplanned LM PCI (performed during or within 24 hours of TAVR due to TAVR-related coronary complications), and post-TAVR LM PCI (performed at least 24 hours after TAVR for LM stenosis not related to the TAVR stent frame). The impact of unprotected versus protected LM and location of the LM stent on outcomes was also assessed.
Results:
One-year mortality was similar between the TAVR plus LM PCI cohort and matched controls (9.4% vs. 10.2%; p = 0.83). There was a trend toward increased target vessel revascularization at 1 year in the TAVR plus LM PCI group (5.5% vs. 1.6%; p = 0.06). There was no difference in 1-year mortality after TAVR plus LM PCI between patients with unprotected, compared to protected LM disease (7.8% vs. 8.1%; hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.32-2.66; p = 0.88). There was no statistically significant difference in 1-year mortality among patients undergoing LM PCI within 3 months prior to TAVR or >3 months prior to TAVR (7.4% vs. 8.6%; HR, 0.76; 95% CI, 0.27-2.17; p = 0.61). There was no statistically significant difference in 1-year survival among patients with or without an ostial LM stent undergoing TAVR (10.3% vs. 15.6%; HR, 2.03; 95% CI, 0.68-6.05; p = 0.20). Unplanned LM PCI was associated with significantly increased 30-day mortality (15.8% vs. 3.4%; HR, 4.91; 95% CI, 1.23-19.64; p = 0.013).
Conclusions:
The authors concluded that LM PCI prior to or during TAVR does not result in increased mortality, compared to TAVR alone.
Perspective:
This is a valuable study, albeit limited by a small sample size. The authors provide evidence that planned LM PCI prior to or during TAVR may be safe and feasible, and that outcomes are not influenced by the presence of unprotected or protected LM, stent location (i.e., ostial or nonostial LM stent), or timing of LM PCI. Such findings are important and may help evolve the paradigm that surgery is the only acceptable treatment for severe aortic stenosis and concurrent LM disease.
Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Constriction, Pathologic, Heart Valve Diseases, Mortality, Myocardial Revascularization, Outcome Assessment, Health Care, Percutaneous Coronary Intervention, Stents, Transcatheter Aortic Valve Replacement
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