Page 75 - Read Online

Page 2 of 11 Raval et al. Vessel Plus 2024;8:5 https://dx.doi.org/10.20517/2574-1209.2023.99

was noted in CoreValve US High Risk trial at 81%, and the lowest prevalence was noted in the Evolut Low
[2,3]
Risk trial at 15% . In a prospective study from the German Aortic Valve Registry of 15,964 patients from
2011-2013, the prevalence of CAD was 55% in the patients undergoing TAVI in a relatively older and high-
[4]
risk population .

Per American College of Cardiology/American Heart Association guidelines, TAVI is preferred for surgical
aortic valve replacement in patients aged > 80 years, patients with a life expectancy < 10 years, or patients
who are at high surgical risk . However, as TAVI has been extended to low-risk patients - given patient
[5]
preference and improved safety - TAVI is becoming the preferred treatment in younger patients who are at
intermediate and even low surgical risk for aortic valve replacement . These patients have a longer life
[6,7]
expectancy and are more likely to develop obstructive CAD or have a progression of underlying CAD that
may not have been significant at the time of TAVI. In elderly patients, TAVI can be safely performed in the
presence of stable CAD without revascularization, and the role of revascularization is uncertain. Thus, the
appropriate diagnosis and management of CAD in patients undergoing TAVI remains unclear.

There is a lack of randomized trials comparing surgical aortic valve replacement with Coronary Artery
Bypass Graft Surgery (CABG) to TAVI and Percutaneous Coronary Intervention (PCI) in patients with
severe aortic stenosis and significant left main and/or multivessel CAD. These patients who are low or
intermediate risk for surgery should have surgical AVR and CABG.

The aim of this article is to review the management of CAD in TAVI patients, with a focus on the
prognostic role of CAD, its evaluation and management before and after TAVI, discuss unresolved issues,
and provide future perspectives.

DISCUSSION
Prognostic role of CAD in patients undergoing TAVI
The impact of CAD on the outcomes of TAVI patients remains uncertain. This has led to differences in the
management of CAD in TAVI patients. There are conflicting results in major studies, with differences in
how CAD is defined and its management, short-duration follow-up data, and less frequent use of fractional
flow reserve (FFR) for physiologic assessment during invasive coronary angiography .
[8]

A meta-analysis of 15 studies comprising a total of 8,013 patients published in 2017 addressed the
[9]
prognostic risk of CAD in TAVI patients . At 30 days post-procedure, no significant difference in the
cumulative odds ratio for all-cause mortality between patients with CAD and without CAD who underwent
TAVI was noted. However, 1-year mortality was higher in the CAD group with a cumulative odds ratio of
1.21. The major limitation of this study was that only a few studies reported all of the secondary endpoints,
including cardiovascular mortality at 30 days, myocardial infarction at 30 days, stroke at 30 days, major
bleeding at 30 days, vascular complications at 30 days, cardiovascular mortality at 1 year, myocardial
infarction at 1 year, and stroke at 1 year. The SYNTAX score, a grading tool to estimate CAD burden,
complexity, and preprocedural risk accounting for complex lesions including bifurcations, chronic total
occlusions, thrombus, calcification, and small diffuse disease , was not utilized in this meta-analysis. The
[10]
separate role of left main coronary artery disease was also not evaluated in this study.

Data from the FRANCE-2 registry showed that only significant lesions in the LAD had an association with
higher 3-year mortality post-TAVI, and neither the presence nor extent of any other CAD was associated
with higher mortality .
[11]