Skip to main content

Advertisement

SpringerLink
Log in

Management of Coronary Artery Disease and Conduction Abnormalities in Transcatheter Aortic Valve Implantation

  • Coronary Artery Disease (D Feldman and V Voudris, Section Editors)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion statement

Transcatheter aortic valve replacement (TAVR) is an expanding, catheter-based technology that allows the implantation of a prosthetic valve without requiring open heart surgery for the treatment of severe aortic stenosis (AS). The frequency of coronary artery disease (CAD) in patients (pts) with severe AS undergoing surgical treatment ranges from 30 to 50 %. This tends to be higher in pts undergoing TAVR with a prevalence of 49–76 % and is more prevalent with older age and the fact that TAVR is commonly performed in high-risk groups with more advanced cardiovascular disease. The overall influence of CAD on TAVR procedural outcomes remains controversial, and the management of concomitant artery disease is still under discussion. There are three major issues that must be addressed: the impact of CAD, optimal timing of percutaneous coronary intervention (PCI) and TAVR, and extent of revascularization. Today, TAVR is commonly performed as a stand-alone procedure with variable degrees of concomitant CAD tolerated without intervention. One of the major potential complications with TAVR is the damage to the conduction system. The requirement of permanent pacemaker (PM) implantation ranges from 9 to 49 % of cases with a mean of ~20 %, whereas surgical aortic valve replacement (sAVR) is associated with a complete heart block that requires permanent PM in 3–12 % of cases. Reports have demonstrated an increased incidence of conduction damage in patients undergoing TAVR with the CoreValve (Medtronic Minneapolis, MN, USA) prosthesis (mean 20.8 %, range 9.3–30.0 %) compared with the Edwards SAPIEN (Edwards Lifesciences LLC; Irvine, CA, USA) prosthesis (mean 5.4 %, range 0–10.1 %). Factors predicting PM implantation include preexisting bundle branch block (BB) or conduction abnormalities. The prognostic significance of new left bundle branch block (LBBB) after TAVR is unclear. In the future, new valve designs may improve the incidence of permanent PM implantation after TAVR.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364(23):2187–98. The first prospective study that showed the efficiency and safety of TAVI in high risk patients.

    Article  CAS  PubMed  Google Scholar 

  2. Sehatzadeh S, Doble B, Xie F, Blackhouse G, Campbell K, Kaulback K, et al. Transcatheter aortic valve implantation (TAVI) for treatment of aortic valve stenosis: an evidence update. Ont Health Technol Assess Ser. 2013;13(1):1–40.

    CAS  Google Scholar 

  3. Tamburino C, Barbanti M, D’Errigo P, Ranucci M, Onorati F, Covello RD, et al. 1-year outcomes after transfemoral transcatheter or surgical aortic valve replacement: results from the Italian OBSERVANT study. J Am Coll Cardiol. 2015;66(7):804–12. The first prospective study that compared TAVR to surgical AVR with propensity matching.

    Article  PubMed  Google Scholar 

  4. Kobayashi J. Changing strategy for aortic stenosis with coronary artery disease by transcatheter aortic valve implantation. Gen Thorac Cardiovasc Surg. 2013;61(12):663–8.

    Article  PubMed  Google Scholar 

  5. Horne Jr A, Reineck EA, Hasan RK, Resar JR, Chacko M. Transcatheter aortic valve replacement: historical perspectives, current evidence, and future directions. Am Heart J. 2014;168(4):414–23.

    Article  PubMed  Google Scholar 

  6. Goel SS, Ige M, Tuzcu EM, Ellis SG, Stewart WJ, Svensson LG, et al. Severe aortic stenosis and coronary artery disease—implications for management in the transcatheter aortic valve replacement era: a comprehensive review. J Am Coll Cardiol. 2013;62(1):1–10. A systematic review of management of CAD in patients undergoing TAVR.

    Article  PubMed  Google Scholar 

  7. Siontis GC, Jüni P, Pilgrim T, Stortecky S, Büllesfeld L, Meier B, et al. Predictors of permanent pacemaker implantation in patients with severe aortic stenosis undergoing TAVR: a meta-analysis. J Am Coll Cardiol. 2014;64(2):129–40. A systematic review of predictors of permanent pacing after TAVR.

    Article  PubMed  Google Scholar 

  8. Panchal HB, Ladia V, Desai S, Shah T, Ramu V. A meta-analysis of mortality and major adverse cardiovascular and cerebrovascular events following transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis. Am J Cardiol. 2013;112(6):850–60.

    Article  PubMed  Google Scholar 

  9. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin 3rd JP, Guyton RA, et al. 2014 AHA/ACC guideline 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. J Thorac Cardiovasc Surg. 2014;148(1):e1–e132. Current guidelines on the management of severe aortic stenosis. Guidelines include indications for pacemaker implantation after surgical procedures.

    Article  PubMed  Google Scholar 

  10. Khawaja MZ, Asrress KN, Haran H, Arri S, Nadra I, Bolter K, et al. 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. 2015;11(4):450–5.

    Article  PubMed  Google Scholar 

  11. Dewey TM, Brown DL, Herbert MA, Culica D, Smith CR, Leon MB, et al. Effect of concomitant coronary artery disease on procedural and late outcomes of transcatheter aortic valve implantation. Ann Thorac Surg. 2010;89(3):758–67.

    Article  PubMed  Google Scholar 

  12. Masson JB, Lee M, Boone RH, Al Ali A, Al Bugami S, Hamburger J, et al. Impact of coronary artery disease on outcomes after transcatheter aortic valve implantation. Catheter Cardiovasc Interv. 2010;76(2):165–73.

    Article  PubMed  Google Scholar 

  13. Gautier M, Pepin M, Himbert D, Ducrocq G, Iung B, Dilly MP, et al. Impact of coronary artery disease on indications for transcatheter aortic valve implantation and on procedural outcomes. EuroIntervention. 2011;5:549–55.

    Article  Google Scholar 

  14. Goel SS, Agarwal S, Tuzcu EM, Ellis SG, Svensson LG, Zaman T, et al. Percutaneous coronary intervention in patients with severe aortic stenosis: implications for transcatheter aortic valve replacement. Circulation. 2012;125(8):1005–13.

    Article  PubMed  Google Scholar 

  15. Gilard M, Eltchaninoff H, Iung B, Donzeau-Gouge P, Chevreul K, Fajadet J, et al. Registry of transcatheter aortic-valve implantation in high-risk patients. N Engl J Med. 2012;366(18):1705–15.

    Article  CAS  PubMed  Google Scholar 

  16. Abdel-Wahab M, Zahn R, Horack M, Gerckens U, Schuler G, Sievert H, et al. Transcatheter aortic valve implantation in patients with and without concomitant coronary artery disease: comparison of characteristics and early outcome in the German multicenter TAVI registry. Clin Res Cardiol. 2012;101(12):973–81.

    Article  PubMed  Google Scholar 

  17. Ussia GP, Barbanti M, Colombo A, Tarantini G, Petronio AS, Ettori F, et al. Impact of coronary artery disease in elderly patients undergoing transcatheter aortic valve implantation: insight from the Italian CoreValve Registry. Int J Cardiol. 2013;167(3):943–50.

    Article  PubMed  Google Scholar 

  18. Snow TM, Ludman P, Banya W, DeBelder M, MacCarthy PM, Davies SW, et al. Management of concomitant coronary artery disease in patients undergoing transcatheter aortic valve implantation: The United Kingdom TAVI Registry. Int J Cardiol. 2015;199:253–60.

    Article  PubMed  Google Scholar 

  19. Abramowitz Y, Banai S, Katz G, Steinvil A, Arbel Y, Havakuk O, et al. Comparison of early and late outcomes of TAVI alone compared to TAVI plus PCI in aortic stenosis patients with and without coronary artery disease. Catheter Cardiovasc Interv. 2014;83(4):649–54.

    Article  PubMed  Google Scholar 

  20. Abdel-Wahab M, Mostafa AE, Geist V, Stöcker B, Gordian K, Merten C, et al. Comparison of outcomes in patients having isolated transcatheter aortic valve implantation versus combined with preprocedural percutaneous coronary intervention. Am J Cardiol. 2012;109(4):581–6.

    Article  PubMed  Google Scholar 

  21. Pasic M, Dreysse S, Unbehaun A, Buz S, Drews T, Klein C, et al. Combined elective percutaneous coronary intervention and transapical transcatheter aortic valve implantation. Interact Cardiovasc Thorac Surg. 2012;14(4):463–8.

    Article  PubMed Central  PubMed  Google Scholar 

  22. Wenaweser P, Pilgrim T, Guerios E, Stortecky S, Huber C, Khattab AA, et al. Impact of coronary artery disease and percutaneous coronary intervention on outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation. EuroIntervention. 2011;7(5):541–8.

    Article  PubMed  Google Scholar 

  23. Conradi L, Seiffert M, Franzen O, Baldus S, Schirmer J, Meinertz T, et al. First experience with transcatheter aortic valve implantation and concomitant percutaneous coronary intervention. Clin Res Cardiol. 2011;100(4):311–6.

    Article  PubMed  Google Scholar 

  24. Gasparetto V, Fraccaro C, Tarantini G, Buja P, D’Onofrio A, Yzeiraj E, et al. Safety and effectiveness of a selective strategy for coronary artery revascularization before transcatheter aortic valve implantation. Catheter Cardiovasc Interv. 2013;81(2):376–83.

    Article  PubMed  Google Scholar 

  25. Van Mieghem NM, van der Boon RM, Faqiri E, Diletti R, Schultz C, van Geuns RJ, et al. Complete revascularization is not a prerequisite for success in current transcatheter aortic valve implantation practice. J Am Cardiol Intv. 2013;6(8):867–75.

    Article  Google Scholar 

  26. Bagur R, Webb JG, Nietlispach F, Dumont E, De Larochellière R, Doyle D, et al. Acute kidney injury following transcatheter aortic valve implantation: predictive factors, prognostic value, and comparison with surgical aortic valve replacement. Eur Heart J. 2010;31(7):865–74.

    Article  PubMed Central  PubMed  Google Scholar 

  27. van Rosendael PJ, van der Kley F, Kamperidis V, Katsanos S, Al Amri I, Regeer M, et al. Timing of staged percutaneous coronary intervention before transcatheter aortic valve implantation. Am J Cardiol. 2015;115(12):1726–32.

    Article  PubMed  Google Scholar 

  28. Zajarias A, Eltchaninoff H, Cribier A. Successful coronary intervention after percutaneous aortic valve replacement. Catheter Cardiovasc Interv. 2007;69(4):522–4.

    Article  PubMed  Google Scholar 

  29. Geist V, Sherif MA, Khattab AA. Successful percutaneous coronary intervention after implantation of a CoreValve percutaneous aortic valve. Catheter Cardiovasc Interv. 2009;73(1):61–7.

    Article  PubMed  Google Scholar 

  30. Ribeiro HB, Webb JG, Makkar RR, Cohen MG, Kapadia SR, Kodali S, et al. Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry. J Am Coll Cardiol. 2013;62(17):1552–62.

    Article  PubMed  Google Scholar 

  31. Ahad S, Baumbach H, Hill S, Franke UF. Transapical aortic valve implantation and minimally invasive off-pump bypass surgery. Interact Cardiovasc Thorac Surg. 2014;18(2):248–9.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Castellant P, Didier R, Bezon E, Couturaud F, Eltchaninoff H, Iung B, et al. Comparison of Outcome of Transcatheter Aortic Valve Implantation With Versus Without Previous Coronary Artery Bypass Grafting (from the FRANCE 2 Registry). Am J Cardiol. 2015;116(3):420–5.

    Article  PubMed  Google Scholar 

  33. Houthuizen P, van der Boon RM, Urena M, Van Mieghem N, Brueren GB, Poels TT, et al. Occurrence, fate and consequences of ventricular conduction abnormalities after transcatheter aortic valve implantation. EuroIntervention. 2014;9:1142–50.

    Article  PubMed  Google Scholar 

  34. Roten L, Stortecky S, Scarcia F, Kadner A, Tanner H, Delacrétaz E, et al. Atrioventricular conduction after transcatheter aortic valve implantation and surgical aortic valve replacement. J Cardiovasc Electrophysiol. 2012;23:1115–22.

    Article  PubMed  Google Scholar 

  35. Bagur R, Rodés-Cabau J, Gurvitch R, Dumont É, Velianou JL, Manazzoni J, et al. Need for permanent pacemaker as a complication of transcatheter aortic valve implantation and surgical aortic valve replacement in elderly patients with severe aortic stenosis and similar baseline electrocardiographic findings. J Am Cardiol Intv. 2012;5:540–51.

    Article  Google Scholar 

  36. Colombo A, Latib A. Left bundle branch block after transcatheter aortic valve implantation: inconsequential or a clinically important endpoint? J Am Coll Cardiol. 2012;60:1753–5.

    Article  PubMed  Google Scholar 

  37. Franzoni I, Latib A, Maisano F, Costopoulos C, Testa L, Figini F, et al. Comparison of incidence and predictors of left bundle branch block after transcatheter aortic valve implantation using the CoreValve versus the Edwards valve. Am J Cardiol. 2013;112:554–9.

    Article  PubMed  Google Scholar 

  38. Kostopoulou A, Karyofillis P, Livanis E, Thomopoulou S, Stefopoulos C, Doudoumis et al. Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors: a single-centre experience. Europace. 2015. doi:10.1093/europace/euv137.

  39. Erkapic D, Kim WK, Weber M, Möllmann H, Berkowitsch A, Zaltsberg S, et al. Electrocardiographic and further predictors for permanent pacemaker requirement after transcatheter aortic valve implantation. Europace. 2010;12:1188–90.

    Article  PubMed  Google Scholar 

  40. Akin I, Kische S, Paranskaya L, Schneider H, Rehders TC, Trautwein U, et al. Predictive factors for pacemaker requirement after transcatheter aortic valve implantation. BMC Cardiovasc Disord. 2012;12:87.

    Article  PubMed Central  PubMed  Google Scholar 

  41. Eksik A, Gul M, Uyarel H, Surgit O, Yildirim A, Uslu N, et al. Electrophysiological evaluation of atrioventricular conduction disturbances in transcatheter aortic valve implantation with Edwards SAPIEN prosthesis. J Invasive Cardiol. 2013;25:305–9.

    PubMed  Google Scholar 

  42. Egger F, Nürnberg M, Rohla M, Weiss TW, Unger G, Smetana P, et al. High-degree atrioventricular block in patients with preexisting bundle branch block or bundle branch block occurring during transcatheter aortic valve implantation. Heart Rhythm. 2014;11:2176–82.

    Article  PubMed  Google Scholar 

  43. Rubín JM, Avanzas P, Calvo D, Morís C. Intra-Hisian block during transcatheter aortic valve implantation with the CoreValve prosthesis. Rev Esp Cardiol. 2011;64:168–9.

    Article  PubMed  Google Scholar 

  44. D’Ancona G, Pasic M, Unbehaun A, Hetzer R. Permanent pacemaker implantation after transapical transcatheter aortic valve implantation. Interact Cardiovasc Thorac Surg. 2011;13:373–6.

    Article  PubMed  Google Scholar 

  45. Ledwoch J, Franke J, Gerckens U, Kuck KH, Linke A, Nickenig G, et al. Incidence and predictors of permanent pacemaker implantation following transcatheter aortic valve implantation: analysis from the German transcatheter aortic valve interventions registry. Catheter Cardiovasc Interv. 2013;82:E569–77.

    PubMed  Google Scholar 

  46. Khawaja MZ, Rajani R, Cook A, Khavandi A, Moynagh A, Chowdhary S, et al. Permanent pacemaker insertion after CoreValve transcatheter aortic valve implantation: incidence and contributing factors (the UK CoreValve Collaborative). Circulation. 2011;123:951–60.

    Article  CAS  PubMed  Google Scholar 

  47. De Carlo M, Giannini C, Bedogni F, Klugmann S, Brambilla N, De Marco F, et al. Safety of a conservative strategy of permanent pacemaker implantation after transcatheter aortic CoreValve implantation. Am Heart J. 2012;163:492–9.

    Article  PubMed  Google Scholar 

  48. Chorianopoulos E, Krumsdorf U, Pleger ST, Katus HA, Bekeredjian R. Incidence of late occurring bradyarrhythmias afterTAVI with the self-expandingCoreValve((R)) aortic bioprosthesis. Clin Res Cardiol. 2012;101:349–55.

    Article  PubMed  Google Scholar 

  49. Munoz-Garcia AJ, Hernandez-Garcia JM, Jimenez-Navarro MF, Alonso-Briales JH, Dominguez-Franco AJ, Fernandez-Pastor J, et al. Factors predicting and having an impact on the need for a permanent pacemaker after CoreValve prosthesis implantation using the new Accutrak delivery catheter system. J Am Cardiol Intv. 2012;5:533–9.

    Article  Google Scholar 

  50. Calvi V, Conti S, Pruiti GP, Capodanno D, Puzzangara E, Tempio D, et al. Incidence rate and predictors of permanent pacemaker implantation after transcatheter aortic valve implantation with self-expanding Core-Valve prosthesis. J Interv Card Electrophysiol. 2012;34:189–95.

    Article  PubMed  Google Scholar 

  51. Mouillet G, Lellouche N, Lim P, et al. Patients without prolonged QRS after TAVI with CoreValve device do not experience high-degree atrio-ventricular block. Catheter Cardiovasc Interv. 2013;81:882–7.

    Article  PubMed  Google Scholar 

  52. Urena M, Webb JG, Tamburino C, Muñoz-García AJ, Cheema A, Dager AE, et al. Permanent pacemaker implantation after transcatheter aortic valve implantation: impact on late clinical outcomes and left ventricular function. Circulation. 2014;129(11):1233–43.

    Article  PubMed  Google Scholar 

  53. Gensas CS, Caixeta A, Siqueira D, Carvalho LA, Mangione JA, on behalf of the Brazilian Registry in Transcatheter Aortic Valve Implantation Investigators, et al. Predictors of permanent pacemaker requirement after transcatheter aortic valve implantation: Insights from a Brazilian Registry. Int J Cardiol. 2014;175:248–52.

    Article  PubMed  Google Scholar 

  54. Nazif TM, Dizon JM, Hahn RT, Xu K, Babaliaros V, Douglas PS, et al. Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement : the PARTNER (placement of AoRtic TraNscathetER valves) trial and registry. J Am Coll Cardiol Intv. 2015;8:60–9.

    Article  Google Scholar 

  55. Kawashima T, Sato F. Visualizing anatomical evidences on atrioventricular conduction system for TAVI. Int J Cardiol. 2014;174:1–6.

    Article  PubMed  Google Scholar 

  56. Jilaihawi H, Chin D, Spyt T, Jeilan M, Vasa-Nicotera M, Bence J, et al. Prosthesis-patient mismatch after transcatheter aortic valve implantation with the Medtronic-Corevalve bioprosthesis. Eur Heart J. 2010;31:857–64.

    Article  PubMed  Google Scholar 

  57. van der Boon RM, Van Mieghem NM, Theuns DA, Nuis RJ, Nauta ST, Serruys PW, et al. Pacemaker dependency after transcatheter aortic valve implantation with the self-expanding Medtronic CoreValve System. Int J Cardiol. 2013;168:1269–73.

    Article  PubMed  Google Scholar 

  58. Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, et al. 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the task force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Europace. 2013;15:1070–118.

    Article  PubMed  Google Scholar 

  59. Piazza N, Nuis RJ, Tzikas A, Otten A, Onuma Y, García-García H, et al. Persistent conduction abnormalities and requirements for pacemaking six months after transcatheter aortic valve implantation. EuroIntervention. 2010;6:475–84.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Cardiology Department, Onassis Cardiac Surgery Center, Syngrou av 356, Kallithea, 17674, Athens, Greece

    Anna Kostopoulou MD, Panagiotis Karyofillis MD, Efthimios Livanis MD, George Karavolias MD, George Theodorakis MD & Vassilis Voudris MD

  2. 2nd University Cardiology Department, Attikon Hospital, University of Athens, Athens, Greece

    John Paraskevaides MD

Authors
  1. Anna Kostopoulou MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Panagiotis Karyofillis MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Efthimios Livanis MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. George Karavolias MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. George Theodorakis MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. John Paraskevaides MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Vassilis Voudris MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anna Kostopoulou MD.

Ethics declarations

Conflict of Interest

Kostopoulou Anna, Karyofillis Panagiotis, Livanis Efthimios, Karavolias George, Theodorakis George, Paraskevaides John, and Vassilis Voudris each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Coronary Artery Disease

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kostopoulou, A., Karyofillis, P., Livanis, E. et al. Management of Coronary Artery Disease and Conduction Abnormalities in Transcatheter Aortic Valve Implantation. Curr Treat Options Cardio Med 18, 9 (2016). https://doi.org/10.1007/s11936-015-0432-8

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11936-015-0432-8

Keywords

Search

Navigation