Fractional flow reserve in patients with coronary artery disease undergoing TAVI: a prospective analysis

  • Anja Stundl
  • Jasmin Shamekhi
  • Svenja Bernhardt
  • Maximilian Starke
  • Baravan Al-Kassou
  • Marcel Weber
  • Alexander Sedaghat
  • Hendrik Treede
  • Eberhard Grube
  • Georg Nickenig
  • Nikos Werner
  • Jan-Malte SinningEmail author
Original Paper



To determine the true prevalence of CAD in AS patients, to detect changes of the hemodynamic significance of coronary lesions following TAVI, to explore to what extent FFR-positive CAD might influence outcome and finally to develop a management algorithm for this patient subset.


From May 2016 to March 2018, diagnostic coronary angiography was performed in 246 patients before TAVI. In the presence of coronary lesions with a diameter stenosis ≥ 50%, FFR was measured. In patients with positive FFR ≤ 0.80, a control angiography was performed 6–8 weeks after TAVI.


The study cohort was 81.0 ± 6.1 years old, 48.4% of the patients were male. 53.3% had concomitant CAD. 35.9% of these patients underwent PCI before TAVI due to functionally significant left main CAD and/or severe stenosis ≥ 90%. 31 patients underwent FFR measurements in cumulative 38 coronary lesions. Prior to TAVI, a negative FFR could be detected in 18 lesions, whereas a positive FFR was found in entirely 20 lesions. A control angiography and FFR measurement was performed in cumulative 13 lesions. Comparing the FFR values, there was no significant difference (0.77 ± 0.04 vs. 0.76 ± 0.08; p = 0.11).


Concomitant CAD was diagnosed in 53.3% of TAVI patients. FFR did not significantly change after TAVI, confirming the validity of FFR to evaluate coronary lesions in this specific clinical setting. Given the low rates of cardiac adverse events, it might therefore be considered to treat coronary stenoses not involving left main and those with a diameter stenosis < 90% after TAVI.


Aortic valve stenosis TAVI Coronary artery disease Myocardial revascularization Fractional flow reserve FFR 



Aortic valve stenosis


Coronary artery disease


Fractional flow reserve


Percutaneous coronary intervention


Quantitative coronary analysis


Surgical aortic valve replacement


Transcatheter aortic valve implantation


Transesophageal echocardiography


Transcatheter heart valve


Valve Academic Research Consortium


Compliance with ethical standards

Conflict of interest

Drs. Sinning, Grube, Nickenig, and Werner receive research grants and speaker honoraria from Medtronic and Edwards Lifesciences. Dr. Grube works as proctor for Medtronic. The other authors report no conflicts.

Supplementary material

392_2019_1563_MOESM1_ESM.docx (15 kb)
Supplementary file1 (DOCX 14 kb)


  1. 1.
    Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M, Dewey T, Kapadia S, Babaliaros V, Thourani VH, Corso P, Pichard AD, Bavaria JE, Herrmann HC, Akin JJ, Anderson WN, Wang D, Pocock SJ, PARTNER Trial Investigators (2011) Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 364(23):2187–2198CrossRefGoogle Scholar
  2. 2.
    Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Brown DL, Block PC, Guyton RA, Pichard AD, Bavaria JE, Herrmann HC, Douglas PS, Petersen JL, Akin JJ, Anderson WN, Wang D, Pocock S, PARTNER Trial Investigators (2010) Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergosurgery. N Engl J Med 363(17):1597–1607CrossRefGoogle Scholar
  3. 3.
    Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, Thourani VH, Tuzcu EM, Miller DC, Herrmann HC, Doshi D, Cohen DJ, Pichard AD, Kapadia S, Dewey T, Babaliaros V, Szeto WY, Williams MR, Kereiakes D, Zajarias A, Greason KL, Whisenant BK, Hodson RW, Moses JW, Trento A, Brown DL, Fearon WF, Pibarot P, Hahn RT, Jaber WA, Anderson WN, Alu MC, Webb JG, PARTNER 2 Investigators (2016) Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 374:1609–1620CrossRefGoogle Scholar
  4. 4.
    Redwood SR, Thomas M (2014) Coronary artery disease in patients undergoing TAVI—why not to treat. EuroIntervention 10(Suppl U):U76–U83PubMedGoogle Scholar
  5. 5.
    Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Jr FDP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS, 2006 Writing Committee Members; American College of Cardiology, American Heart Association Task Force (2008) Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008(118):e523–e661. CrossRefGoogle Scholar
  6. 6.
    Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic' PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO (2019) 2018 ESC/EACTS Guidelines on myocardial revascularization. The Task Force on myocardial revascularization of the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS). G Ital Cardiol (Rome) 20(7):1–61Google Scholar
  7. 7.
    Snow TM, Ludman P, Banya W, DeBelder M, MacCarthy PM, Davies SW, Di Mario C, Moat NE (2015) Management of concomitant coronary artery disease in patients undergoing transcatheter aortic valve implantation: the United Kingdom TAVI Registry. Int J Cardiol 199:253–260. CrossRefPubMedGoogle Scholar
  8. 8.
    Goel SS, Ige M, Tuzcu ME et al (2013) Severe aortic stenosis and coronary artery diseased implications for management in the transcatheter aortic valve replacement era: a comprehensive review. J Am Coll Cardiol 62:1–10CrossRefGoogle Scholar
  9. 9.
    Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Rodriguez Muñoz D, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL, ESC Scientific Document Group (2017) 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 38(36):2739–2791CrossRefGoogle Scholar
  10. 10.
    Rapp AH, Hillis LD, Lange RA, Cigarroa JE (2001) Prevalence of coronary artery disease in patients with aortic stenosis with and without angina pectoris. Am J Cardiol 87(10):1216–1217CrossRefGoogle Scholar
  11. 11.
    Vandeplas A, Willems JL, Piessens J, Geest H (1988) Frequency of angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis. Am J Cardiol 62(1):117–120CrossRefGoogle Scholar
  12. 12.
    Stewart BF, Siscovick D, Lind BK, Gardin JM, Gottdiener JS, Smith VE, Kitzman DW, Otto CM (1997) Clinical factors associated with calcific aortic valve disease. Cardiovascular health study. J Am Coll Cardiol 29(3):630–634CrossRefGoogle Scholar
  13. 13.
    Khawaja MZ, Asrress KN, Haran H, Arri S, Nadra I, Bolter K, Wilson K, Clack L, Hancock J, Young CP, Bapat V, Thomas M, Redwood S (2015) The effect of coronary artery disease defined by quantitative coronary angiography and SYNTAX score upon outcome after transcatheter aortic valve implantation (TAVI) using the Edwards bioprosthesis. Eurointervention 11:450–455CrossRefGoogle Scholar
  14. 14.
    Dewey TM, Brown DL, Herbert MA, Culica D, Smith CR, Leon MB, Svensson LG, Tuzcu M, Webb JG, Cribier A, Mack MJ (2010) Effect of concomitant coronary artery disease on procedural and late outcomes of transcatheter aortic valve implantation. Ann Thorac Surg 89:758–767CrossRefGoogle Scholar
  15. 15.
    Masson JB, Lee M, Boone RH, Al Ali A, Al Bugami S, Hamburger J, John Mancini GB, Ye J, Cheung A, Humphries KH, Wood D, Nietlispach F, Webb JG (2010) Impact of coronary artery disease on outcomes after transcatheter aortic valve Implantation. Catheter Cardiovasc Interv 76:165–173CrossRefGoogle Scholar
  16. 16.
    Wenaweser P, Pilgrim T, Guerios E, Stortecky S, Huber C, Khattab AA, Kadner A, Buellesfeld L, Gloekler S, Meier B, Carrel T, Windecker S (2011) Impact of coronary artery disease and percutaneous coronary intervention on outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation. EuroIntervention 7:541–548CrossRefGoogle Scholar
  17. 17.
    D’Ascenzo F, Conrotto F, Giordana F, Moretti C, D’Amico M, Salizzoni S, Omedè P, La Torre M, Thomas M, Khawaja Z, Hildick-Smith D, Ussia G, Barbanti M, Tamburino C, Webb J, Schnabel RB, Seiffert M, Wilde S, Treede H, Gasparetto V, Napodano M, Tarantini G, Presbitero P, Mennuni M, Rossi ML, Gasparini M, Biondi Zoccai G, Lupo M, Rinaldi M, Gaita F, Marra S (2013) Mid-term prognostic value of coronary artery disease in patients undergoing transcatheter aortic valve implantation: a meta-analysis of adjusted observational results. Int J Cardiol 168:2528–2532CrossRefGoogle Scholar
  18. 18.
    Penkalla A, Pasic M, Drews T, Buz S, Dreysse S, Kukucka M, Mladenow A, Hetzer R, Unbehaun A (2015) Transcatheter aortic valve implantation combined with elective coronary artery stenting: a simultaneous approach†. Eur J Cardiothorac Surg 47:1083–1089CrossRefGoogle Scholar
  19. 19.
    van de Hoef TP, Meuwissen M, Escaned J, Davies JE, Siebes M, Spaan JA, Piek JJ (2013) Fractional flow reserve as a surrogate for inducible myocardial ischaemia. Nat Rev Cardiol 10:439–452CrossRefGoogle Scholar
  20. 20.
    Wiegerinck EM, van de Hoef TP, Rolandi MC, Yong Z, van Kesteren F, Koch KT, Vis MM, de Mol BA, Piek JJ, Baan J Jr (2015) Impact of aortic valve stenosis on coronary hemodynamics and the instantaneous ef- fect of transcatheter aortic valve implantation. Circ Cardiovasc Interv 8:e0024CrossRefGoogle Scholar
  21. 21.
    Ben-Dor I, Malik R, Minha S, Goldstein SA, Wang Z, Magalhaes MA, Weissman G, Okubagzi PG, Torguson R, Lindsay J, Satler LF, Pichard AD, Waksman R (2014) Coronary blood flow in patients with severe aortic stenosis before and after transcatheter aortic valve implantation. Am J Cardiol 114:1264–1268. CrossRefPubMedGoogle Scholar
  22. 22.
    Davies JE, Sen S, Broyd C, Hadjiloizou N, Baksi J, Francis DP, Foale RA, Parker KH, Hughes AD, Chukwuemeka A, Casula R, Malik IS, Mikhail GW, Mayet J (2011) Arterial pulse wave dynamics after percutaneous aortic valve replacement: fall in coronary diastolic suction with increasing heart rate as a basis for angina symptoms in aortic stenosis. Circulation 124:1565–1572. CrossRefPubMedGoogle Scholar
  23. 23.
    Rolandi MC, Wiegerinck EM, Casadonte L, Yong ZY, Koch KT, Vis M, Piek JJ, Baan J Jr, Spaan JA, Siebes M (2016) Transcatheter replacement of stenotic aortic valve normalizes cardiac-coronary interaction by restoration of systolic coronary flow dynamics as assessed by wave intensity analysis. Circ Cardiovasc Interv 9:e002356. CrossRefPubMedGoogle Scholar
  24. 24.
    Pesarini G, Scarsini R, Zivelonghi C, Piccoli A, Gambaro A, Gottin L, Rossi A, Ferrero V, Vassanelli C, Ribichini F (2016) Functional assessment of coronary artery disease in patients undergoing transcatheter aortic valve implantation: influence of pressure overload on the evaluation of lesions severity. Circ Cardiovasc Interv 9(11):e004088CrossRefGoogle Scholar
  25. 25.
    Mancio J, Fontes-Carvalho R, Oliveira M, Caeiro D, Braga P, Bettencourt N, Ribeiro VG (2015) Coronary artery disease and symptomatic severe aortic valve stenosis: clinical outcomes after transcatheter aortic valve implantation. Front Cardiovasc Med 2:1–7CrossRefGoogle Scholar
  26. 26.
    Gautier M, Pepin M, Himbert D, Ducrocq G, Iung B, Dilly M-P, Attias D, Nataf P, Vahanian A (2011) Impact of coronary artery disease on indications for transcatheter aortic valve implantation and on procedural outcomes. EuroIntervention 7:549–555CrossRefGoogle Scholar
  27. 27.
    Taha S, Moretti C, D’Ascenzo F, Van Mieghem NM, Omede P, Montefusco A, Ghany MA, Fouaad D, Demitry S, Zoccai GB, Gaita F (2015) Impact of residual coronary artery disease on patients undergoing TAVI: a meta-analysis of adjusted observational studies. Int J Cardiol 181:77–80CrossRefGoogle Scholar
  28. 28.
    Sankaramangalam K, Banerjee K, Kandregula K, Mohananey D, Parashar A, Jones BM, Jobanputra Y, Mick S, Krishnaswamy A, Svensson LG, Kapadia SR (2017) Impact of coronary artery disease on 30-day and 1-year mortality in patients undergoing transcatheter aortic valve replacement: a meta-analysis. J Am Heart Assoc 6(10):e006092. CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Anja Stundl
    • 1
  • Jasmin Shamekhi
    • 1
  • Svenja Bernhardt
    • 1
  • Maximilian Starke
    • 1
  • Baravan Al-Kassou
    • 1
  • Marcel Weber
    • 1
  • Alexander Sedaghat
    • 1
  • Hendrik Treede
    • 2
  • Eberhard Grube
    • 1
  • Georg Nickenig
    • 1
  • Nikos Werner
    • 1
  • Jan-Malte Sinning
    • 1
    Email author
  1. 1.Heart Center Bonn, Department of Medicine IIUniversity Hospital BonnBonnGermany
  2. 2.Heart Center, Department of Cardiac SurgeryUniversity Hospital BonnBonnGermany

Personalised recommendations