Coronary heart disease and aortic stenosis

How to manage in the times of TAVR?

When TAVR was indicated only for patients at high surgical risk, the presence of coronary artery disease (CAD) in patients who underwent this procedure reached an expressive mark of 80% in the largest cohort studies. Currently, with the addition of low-risk patients in the follow-up of these cohort studies, these values have been reduced to something around 50% and with a tendency to decrease.

About half of the patients undergoing TAVR currently have multivessel disease, with a mean Syntax score of 14, with the anterior descendent affected in 50% of cases.

Several meta-analyzes have brought an interesting debate, in which coronary artery disease may not be an isolated factor of poor prognosis, but rather a marker of the patient’s severity, given its complexity. However, the overwhelming majority of work has a short follow-up and CAD can change its status in the long run.

In search of less and less invasive procedures, alternative methods for the diagnosis of CAD are gaining ground, such as coronary angiotomography, which has shown a power to reduce coronary angiography by up to 37%, and may present even better results in a population little younger and with less surgical risk.

Another recent but invasive method is the FFR or iFR. Once the lesion is indicated by cineangiography and there is no clear evidence of myocardial ischemia, functional flow analysis may be relevant to indicate an adequate coronary revascularization concomitant with TAVR, but it should be kept in mind that aortic stenosis can alter the coronary flow reserve as we can see in this post here on our platform.

In order to make the discussion more interesting, the treatment of stable pre-procedure CAD does not seem to add long-term benefit. However, several studies present heterogeneous data, since the indication for coronary intervention ended up following the opinion of the local specialist, which may have interfered with the long-term results. What we have in the literature is that patients who are left with residual injury, that is, those with incomplete revascularization, seem to have a worse prognosis than those with complete revascularization.

Currently, there are insufficient data to differentiate the benefit of performing coronary angioplasty before or during TAVR. Apparently, both procedures are safe with the same outcomes, and each service is responsible for defining its routine.

If the question is about the impact of coronary disease after TAVR, the current data show that the vast majority of events occur without elevation of the ST segment and have a clear negative prognostic impact on evolution. Because they share the same risk factors, in the presence of senile aortic stenosis, CAD has a high prevalence and ought to be extra care in this group of patients. Therefore, the concern with coronary accesses after the bioprosthesis deployment is a concern, but apparently virtual, since there are few cases in which there is a real difficulty in catheterizing the coronary ostium for percutaneous treatment. We would say that perhaps this care exists in self-expanding prostheses, given the higher profile with occupation of the ascending aorta.

Suggested literature:

1 – Faroux L, Guimaraes L, Wintzer-Wehekind J, et al. Coronary Artery Disease and Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review. J Am Coll Cardiol. 2019 Jul 23;74(3):362-372.

 

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