TAVR and Coronary Artery Disease

TAVR and Coronary Artery Disease Ioannis Iakovou, MD, PhD Interventional Cardiology Onassis Cardiac Surgery Center Athens, Greece

TAVR and Coronary Artery Disease Frequency of Concomitant Severe AS and CAD? Impact of CAD on SAVR and TAVR outcomes? Management of CAD in the Setting of TAVR Is PCI Necessary? Can PCI be Performed Safely with AS Timing PCI First? At Time of TAVR? After TAVR? Is Aggressive Revascularization (PCI) Better than Conservative? Stent Type DES vs BMS?

Severe aortic stenosis and coronary artery disease EuroIntervention 2013;9:S63-S68

Severe aortic stenosis and coronary artery disease the prevalence of CAD is extremely high in this patient population, ranging from 44% to 75% in major TAVI studies EuroIntervention 2013;9:S63-S68 2013 EuroIntervention. All rights reserved.

Impact of Coronary Artery Disease 1,637 patients with severe AS without CAD who underwent AVR alone (isolated AS group) 2,286 patients with severe AS and CAD who underwent AVR and CABG (ASCAD) Beach JM, et al J Am Coll Cardiol 2013;61:837-48

Severe aortic stenosis and coronary artery disease CABG at the time of SAVR neutralises the adverse effects of CAD among patients with otherwise similar non-cad-related comorbidities EuroIntervention 2013;9:S63-S68 2013 EuroIntervention. All rights reserved.

TAVR 30 days Mortality: CAD vs no CAD Stefanini GG, EuroIntervention 2013;9:S63-S68

TAVR and Need For Revascularization Procedural concerns during TAVR ---Risk of inducing hemodynamic instability due to significant untreated proximal CAD large area of myocardium at risk 345 procedures (TF: 168, TA: 177) Rodes-Cabau et al. J Am Coll Cardiol 2010;55: 1080 90

Timing of PCI in patients with CAD and AS Goel S, et al. J Am Coll Cardiol 2013;62:1 10

Timing of PCI in patients with CAD and TAVR 2-year survival rates were comparable between those who had PCI within compared with more than 30 days before TAVR (75% vs 77%; P =.363) Am J Cardiol. 2015

Timing of PCI in patients with CAD and AS PCI prior to TAVR Pros Simplified access to coronaries, less ischemia during TAVR, and separate contrast loads Cons Bleeding -DAPT started prior to TAVR (non-femoral access), and PCI higher risk in setting of AS PCI after TAVR Pros PCI lower risk after AS fixed and no DAPT concerns Cons Access to coronaries more difficult, and more ischemia during TAVI PCI and TAVR in same setting? Pros Single procedure and no delay after PCI for TAVR Cons Contrast and procedural duration

From: A Practical Guide to Multimodality Imaging of Transcatheter Aortic Valve Replacement A single-center cohort of consecutive patients undergoing TAVR evaluated for the presence of significant CAD. EuroSCORE 17.63 +/-10.41 263 consecutive patients underwent TAVR with a median follow-up duration of 16 months J Am Coll Cardiol Intv. 2013;6:867 75

Completeness of Revascularization and TAVR J Am Coll Cardiol Intv. 2013;6:867 75

BMS vs. DES Decision should be made based primarily on clinical and anatomic factors independent from TAVR (bleeding risk atrial fibrillation, lesion complexity, or risk of DAPT with TA or DA valve implant) Potentially difficult access to coronaries post TAVR, lower risk of stent thrombosis with contemporary DES, and avoidance of further procedures in these high risk patients suggests when all else equal - DES > BMS

The TAVR-LM Registry 204 patients undergoing TAVR plus LM PCI 128 matched patient pairs (1:1 case-control matching between 167 patients with pre-existing LM stents undergoing TAVR and 1,188 control patients undergoing TAVR without LM revascularization) One-year mortality (9.4% vs. 10.2%, p = 0.83) was similar between the TAVR plus LM PCI cohort and matched controls Unplanned LM PCI performed because of TAVR-related coronary complication, compared with planned LM PCI performed for pre-existing LM disease, resulted in increased 30-day (15.8% vs. 3.4%, p = 0.013) and 1-year (21.1% vs. 8.0%, p = 0.071) mortality J Am Coll Cardiol 2016 Mar 1;67(8):951-60

Case CAD and AS 84 years, female with severe AS (STS 12.5%) and LM stenosis

Case CAD and AS Provisional stenting!resolute integrity 4 x18, POT (NC Sprinter 4.5 x12 ) and FKB

Case CAD and AS Corevalve No 26

ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention Circulation 2011;124:e574-651

Conclusions Severe, proximal/ostial stenoses of large major coronary arteries prior to TAVR are being treated to enhance procedural safety PCI in setting of severe AS is not low risk particularly in low EF and high STS patients BAV and/or hemodynamic support may be useful In high risk TAVR population, no compelling evidence to suggest aggressive revascularization better than targeted therapy less is more Current practice varies including the use of BMS vs DES (maybe better) and timing of when PCI is performed