Coronary Physiology Key to Guiding Revascularization in Severe Aortic Stenosis

In patients who are receiving transcatheter aortic valve replacement (TAVR), the presence of coronary artery disease (CAD) and its anatomical complexity are associated with significantly worse 5-years outcomes, without any clear beneficial effects demonstrated with the use of angiography-guided percutaneous coronary intervention (PCI). These findings were published in JACC: Cardiovascular Interventions.

A prospective, observational study was conducted among all individuals receiving TAVR at a single tertiary referral center in Leuven, Belgium, between 2008 and 2020. Researchers sought to establish whether the presence of CAD, its complexity, and the use of angiography-guided PCI are associated with outcomes following TAVR. The primary study outcome was all-cause death and cardiovascular (CV) death after 5 years. CV death was defined as death from a primary CV cause, including myocardial infarction, heart failure, sudden cardiac death, and stroke, as well as death due to CV procedures and other CV causes as defined by a 2017 consensus report by the Standardized Data Collection for Cardiovascular Trials Initiative and the US Food and Drug Administration.

Baseline Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score and, whenever applicable, a residual SYNTAX score following PCI were calculated. Per multivariate analysis, the effect of CAD, stratified according to complexity, and PCI on 5-year patient outcomes was evaluated.

Among a total of 604 individuals who were scheduled for TAVR, 346 had obstructive CAD. Among these patients, 242 had a low SYNTAX score, 104 had complex CAD, and 107 received pre-TAVR PCI. Among those who received PCI, reasonably complete revascularization was attained in 61.7% of them.

No significant differences in all-cause death were reported between patients with or without CAD, with varying CAD complexity, with or without PCI, or with or without reasonably complete revascularization at 1, 2, and 3 years following TAVR.

At the 5-year follow-up, however, those individuals with CAD exhibited significantly worse survival (CAD: 55.1% vs no CAD: 67.9%; hazard ratio [HR], 1.41; P =.022). Additionally, patients with varying levels of CAD complexity had significantly different outcomes at 5 years following TAVR, with those in the most complex group exhibiting the worse prognosis (SYNTAX score 0: 67.9% vs SYNTAX score 1-22: 56.1% vs SYNTAX score >22: 53.0%; log rank P =.027).

No significant effect of PCI on all-cause death was observed at 5 years after TAVR (no PCI: 56.0% vs PCI: 52.6%; P =.162) among participants with CAD or reasonably complete revascularization (residual SYNTAX score 0-7: 52.2% vs residual SYNTAX score ≥8: 52.7%; P =.678) among those receiving PCI.

With respect to CV death, no significant differences were reported among the groups at the 1-year, 2-year, and 3-year time points. At 5 years following TAVR, however, participants with CAD exhibited significantly higher CV mortality than did those without CAD (CAD: 25.1% vs no CAD: 15.1%; HR, 1.62; P =.039). Additionally, the risk for CV death increased progressively with more complex CAD (SYNTAX score 0: 15.1% vs SYNTAX score 1-22: 24.0% vs SYNTAX score more than 22: 27.8%; log rank P =.024).

The presence of noncomplex CAD (SYNTAX score 1-22) was an independent predictor of increased all-cause mortality (HR, 1.43; P =.046), whereas the presence of complex CAD (SYNTAX score >22) was associated with statistically significant increased CV mortality (HR, 1.84; P =.041).

No significant variations in CV mortality were observed among the patients with CAD who had received PCI. Further, similar outcomes were reported among patients who received PCI, regardless of the completeness of the revascularization procedure.

Study limitations include that this analysis is not a randomized study, and the decision to perform PCI in certain individuals with CAD might be biased by their comorbidities, such as frailty. Such potential selection biases might have had an effect both on all-cause mortality and on CV mortality in the different groups. Additionally, when the study was terminated, not all of the patients had completed the 5-year follow-up period.

The investigators concluded that the findings from the study indicate that “angiography-guided PCI did not improve outcomes, highlighting the need for further research into physiology-guided PCI.”

Disclosure: One of the study authors has declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of the author’s disclosures.

Reference

Minten L, Wissels P, McCutcheon K, et al. The effect of coronary lesion complexity and preprocedural revascularization on 5-year outcomes after TAVR. JACC Cardiovasc Interv. Published online August 15, 2022. doi:10.1016/j.jcin.2022.06.019