Closer Look at Effects of CAD on TAVR Outcomes Unearths Grim Prognosis

PARIS, France—Coronary artery disease complicates TAVR procedures, increasing a patient’s risk of death and worsening overall prognosis within 1 year, according to an age- and sex-matched cohort study.

The prevalence of CAD among TAVR patients is about 50% to 75% in contemporary populations, but its impact on early mortality after a transcatheter aortic valve procedure has been up for debate. 

Presenting the results at EuroPCR 2016, Anna Franzone, MD (Bern University Hospital, Switzerland), explained how her team examined the effects of CAD on TAVR patients. They divided 795 patients from the Bern TAVI Registry and 3,528 patients from the Bern PCI Registry who were treated between March 2009 and November 2013 into three matched groups of 248 patients each:

•  TAVR + CAD
•  TAVR without CAD
•  PCI only

Compared with the TAVR + CAD cohort (16.8%), those who received TAVR without CAD (9.8%) and those who underwent PCI only (9.5%) had lower rates of the prespecified composite endpoint of cardiovascular death, cerebrovascular events, or MI (MACCE) at 1 year. This difference was mainly driven by higher rates of cardiovascular mortality in the TAVR + CAD group (12.7%) compared with TAVR without CAD (7.0%) and PCI (5.8%).

Rates of MACCE and cardiovascular mortality did not differ between the TAVR without CAD and PCI-only patients. Also, at 1 year there was a fourfold increase in risk of death for the patients in all three study cohorts compared with the general population, but the highest mortality ratios were found in the TAVR + CAD cohort.

More Data, Guidelines Needed

Remarking on the fact that only 36.3% of the TAVR + CAD patients had received previous PCI, panelist Mao-Shin Lin, MD (National Taiwan University Hospital, Taipei), wondered why. “In our practice, I would think if the patient [had] CAD, we would fix the [coronary] disease before [TAVR],” he said.  

Franzone explained that this is reflective of the “current lack of standardized guidelines to manage this issue before [TAVR].” Her institution follows a protocol in which all patients with significant coronary lesions undergo revascularization. However, “we did not find significant differences in 30-day or 1-year outcomes in patients undergoing PCI compared with patients [who did not receive PCI],” she said.

When panel moderator Ganesh Manoharan, MBBCh, MD (Royal Victoria Hospital, Belfast, Northern Ireland), asked if PCI was generally triggered by anatomy or symptoms, Franzone said it was mostly based on visual estimation in her study. 

While it would be “a bit more complex to repeat this again,” Manoharan said it might be helpful to know which patients have ischemic versus nonischemic burden with hemodynamic assessment. “Because if there was a 1% or 2% difference, that will change your graph significantly. It’s a challenge for all of us who do TAVR in CAD,” he said, adding that some patients might seem like they would do well with TAVR, but in reality do not.

“It’s like an additive effect of concomitant coronary artery disease,” Franzone agreed. “Probably it does not affect the outcomes in terms of ischemic events, but we see that cardiac mortality is higher. That means that cardiac function is impaired more than if we considered solely . . . the presence of aortic stenosis.”

As far as what her institution might change going forward, Franzone said they really need to understand the prognostic impact of CAD on patients undergoing TAVR. “We know almost everything about elderly patients undergoing PCI. We know how they behave in the long term and what their prognosis is, and we consider this a good standard to compare the populations of [TAVR] patients with concomitant coronary artery disease,” she said. “From a practical point of view, I think we will continue to manage the patients with baseline preliminary revascularization until we have more data to clearly address the role of CAD.”

•  Franzone A. Impact of coronary artery disease on clinical outcomes among patients undergoing transcatheter aortic valve implantation: an age- and sex-matched cohort study. Presented at: EuroPCR 2016. May 18, 2016. Paris, France.

Disclosure:

•  Franzone reports receiving institutional grant/research support from MSD and the Italian Society of Cardiology and travel support from Biotronik.

Related Stories:

•  Length of Time Between Staged PCI, TAVR Minimally Affects Short-term Outcomes
•  Incomplete Revascularization Linked to Poorer Outcomes in TAVR Patients With CAD 
•  Incomplete Revascularization Does Not Hinder TAVR for Severe Aortic Stenosis