Revascularization With Aortic Valve Replacement for Aortic Stenosis

Authors:
Patel KP, Michail M, Treibel TA, et al.
Citation:
Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis. JACC Cardiovasc Interv 2021;14:2083-2096.

The following are key points to remember from this state-of-the-art review on coronary revascularization in patients undergoing aortic valve replacement (AVR) for severe aortic stenosis (AS).

  1. AS and coronary artery disease (CAD) frequently coexist, with up to two thirds of patients with AS having significant CAD.
  2. Given the challenges when both disease states are present, these patients require a tailored approach diagnostically and therapeutically.
  3. Remodeling in AS increases the susceptibility of myocardial ischemia, which can be compounded by concomitant CAD. AVR can improve coronary hemodynamic status and reduce ischemia.
  4. Assessment of the significance of coexisting CAD can be done using noninvasive and invasive metrics. Revascularization in patients undergoing AVR can benefit certain patients in whom CAD is either prognostically or symptomatically important.
  5. Identifying this cohort of patients is challenging and as yet incomplete. Patients with dual pathology present a diagnostic and therapeutic challenge; both AS and CAD affect coronary hemodynamic status, they provoke similar symptoms, and their respective treatments can have an impact on both diseases.
  6. Decisions regarding coronary revascularization should be based on understanding this complex relationship, using appropriate coronary assessment, and consensus within a multidisciplinary team.
  7. Patients with left main stem stenoses <50%, intermediate proximal stenoses (40%-70%), or nonproximal stenoses (50%-90%) should undergo functional assessment, with the only existing, albeit limited, evidence supporting the use of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR).
  8. Noninvasive imaging to guide revascularization within the context of AS is an attractive prospect with computed tomography (CT)-derived FFR in particular, as preprocedural CT will be undertaken in almost all patients being considered for transcatheter aortic valve replacement (TAVR), but needs prospective validation.
  9. For patients deemed appropriate for revascularization where equipoise remains, performing valve replacement in the first instance, using a prosthesis that will permit future revascularization, is a reasonable option.
  10. Finally, prospective studies evaluating the efficacy of revascularization in patients with AS are needed.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Computed Tomography, Nuclear Imaging

Keywords: Aortic Valve Stenosis, Cardiovascular Surgical Procedures, Constriction, Pathologic, Coronary Artery Disease, Coronary Stenosis, Diagnostic Imaging, Fractional Flow Reserve, Myocardial, Heart Valve Diseases, Heart Valve Prosthesis, Hemodynamics, Ischemia, Myocardial Ischemia, Myocardial Revascularization, Patient Care Team, Secondary Prevention, Tomography, X-Ray Computed, Transcatheter Aortic Valve Replacement


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