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Unplanned PCI After TAVR
Quick Takes
- Unplanned PCI after TAVR is rare (<1% incidence).
- The most common cause for PCI is acute coronary syndrome <2 years after TAVR and chronic coronary syndrome >2 years after TAVR.
- Success rates for PCI are high regardless of TAVR type.
Study Questions:
What is the incidence, timing, and cause of unplanned percutaneous coronary intervention (PCI) after transcatheter aortic valve replacement (TAVR)?
Methods:
Data were retrospectively reviewed for patients undergoing unplanned PCI after TAVR from the international, multicenter REVIVAL (REVascularization after Implantation of transcatheter aortic VALve bioprosthesis) registry.
Results:
Over an 11-year period (July 2008–March 2019), 133 patients (0.9%; from a total cohort of 15,325) underwent unplanned PCI after TAVR (36.1% after balloon-expandable bioprosthesis, 63.9% after self-expandable bioprosthesis). The median time to PCI was 191 days (interquartile range, 59-480 days). The daily incidence of PCI was highest during the first week after TAVR and then declined over time. Overall, the majority of patients underwent PCI due to an acute coronary syndrome, and specifically 32.3% had non–ST-segment elevation myocardial infarction, 15.4% had unstable angina, 9.8% had ST-segment elevation myocardial infarction, and 2.2% had cardiac arrest. However, chronic coronary syndromes were the main indication beyond 2 years. PCI success was reported in almost all cases (96.6%), with no significant differences between patients treated with balloon-expandable and self-expandable bioprostheses (100% vs. 94.9%; p = 0.150).
Conclusions:
Unplanned PCI after TAVR is rare, with an incidence declining over time after TAVR. The main indication to PCI is acute coronary syndrome in the first 2 years after TAVR, and thereafter chronic coronary syndromes become prevalent. Unplanned PCIs are frequently successfully performed after TAVR, with no apparent differences between balloon-expandable and self-expandable bioprostheses.
Perspective:
This retrospective analysis shows low and declining incidence of unplanned PCI after TAVR. In addition, it appears that success rates for PCI after TAVR, regardless of type of valve, are excellent. Findings are limited by selection bias due to the fact that all patients undergoing TAVR also undergo coronary angiography pre-TAVR and those with high-grade coronary artery disease are oftentimes treated prior to TAVR. Nonetheless, guideline-directed medical management and secondary prevention remain important for this cohort of patients after TAVR with appropriate PCI when indicated.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and SIHD, Cardiac Surgery and VHD, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina
Keywords: Acute Coronary Syndrome, Angina, Unstable, Bioprosthesis, Coronary Angiography, Coronary Artery Disease, Heart Arrest, Heart Valve Diseases, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Secondary Prevention, ST Elevation Myocardial Infarction, Transcatheter Aortic Valve Replacement
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