Coexisting Left Main Disease Should Not Rule Out TAVR

Planned PCI of the left main (LM) can be managed safely in patients undergoing TAVR, resulting in 1-year mortality rates similar to those of patients undergoing TAVR alone, according to results of a registry study published in the March 1, 2016, issue of the Journal of the American College of Cardiology. 

“The presence of coexisting LM disease in patients with severe [aortic stenosis] should not deter physicians from evaluating patients for TAVR,” Tarun Chakravarty, MD, of Cedars-Sinai Medical Center (Los Angeles, CA), and colleagues write.

For the TAVR-LM registry, they enrolled 204 patients who underwent both TAVR and left main PCI (either before, during or more than 24 hours after TAVR) between 2007 and 2014. Matching between 167 of these patients and 1,188 controls undergoing TAVR alone was performed to create 128 pairs. The remaining 39 TAVR/LM patients, all of whom had preexisting left main stents, could not be matched.

No Difference in Outcomes  

Rates of procedural, 30-day, and 1-year mortality were similar between the matched TAVR/LM patients and controls.

Sensitivity analysis in patients who could not be matched also showed no difference in rates of 1-year mortality compared with the TAVR/LM cohort. Other comparisons—including between patients with unprotected vs protected LM, those undergoing LM PCI within 3 months vs more than 3 months before TAVR, and those with ostial vs non-ostial stents—also showed no difference in 1-year mortality.

An examination of planned vs unplanned LM PCI revealed greater incidence of cardiogenic shock, need for cardiopulmonary resuscitation, and acute kidney injury (AKI) in the unplanned group. Additionally, unplanned procedures, which were performed because of TAVR-related coronary complication, were associated with significantly increased 30-day mortality and a trend toward higher mortality at 1 year.

Predictors of 1-year mortality were unplanned procedures, need for a second valve, AKI, and low body weight.

“Despite the anatomic proximity between the aortic annulus and LM, TAVR plus LM PCI is safe and technically feasible, with clinical outcomes comparable with those in patients undergoing TAVR alone,” Chakravarty and colleagues write.

Part of the success, said senior author Raj R. Makkar, MD, also of Cedars-Sinai Medical Center, in an interview with TCTMD, can be credited to increasing operator comfortability with both LM stenting and TAVR, as well as better understanding of the factors that predispose patients to coronary occlusion and “being proactive in protecting the left main coronary artery, which should minimize complications.”

Outdated Concerns

In an accompanying editorial, Marco Barbanti, MD, of Ferrarotto Hospital (Catania, Italy), adds that such cases require careful patient selection and pre-TAVR screening with multidetector CT. That imaging technology “probably represents the most important tool for assessing the risk for LM occlusion or LM stent impingement during valve deployment,” he observes. “Besides providing precise aortic root measurements, it allows operators to obtain information regarding LM stent protrusion and potential interaction between the frame of the prosthesis and the calcified aortic cusp with the LM stent once the valve is deployed.”

Barbanti also notes that early concerns about performing TAVR in patients with LM disease “have emerged as more theoretical than real, and today PCI is performed, even after TAVR, without any particular issues, no matter what type of prosthesis is implanted.”

That is not to say, however, that significant LM disease in the context of TAVR should be taken lightly, he cautions, adding that in addition to experience and planning, another important tool clinicians need when dealing with these cases is “common sense.”

“[T]he important thing here is that patients in whom we did this in a planned fashion, the outcomes are very similar to TAVR alone,” Makkar said. “So despite concerns that it leads to higher risk and the outcomes are uncertain . . . patients who have concomitant left main coronary artery disease and aortic stenosis should not be rejected for TAVR procedures.”

Sources:  
1. Chakravarty T, Sharma R, Abramowitz Y, et al.. J Am Coll Cardiol. 2016;67:951-960.
2. Barbanti M. TAVR and left main stenting: can 2 giants live in harmony in a small room [editorial]? J Am Coll Cardiol. 2016;67:961-962. 

Disclosures:

• Makkar is the principal investigator for the St. Jude Medical Portico trial and reports receiving research grants from Edwards Lifesciences, Medtronic, and St. Jude Medical and consulting fees from Edwards. 
• Barbanti reports serving as a consultant for Edwards Lifesciences. 

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• Incomplete Revascularization Does Not Hinder TAVR for Severe Aortic Stenosis
• Length of Time Between Staged PCI, TAVR Minimally Affects Short-term Outcomes