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Percutaneous Coronary Intervention Pre-TAVR: Current State of the Evidence

  • Valvular Heart Disease (TL Kiefer, Section Editor)
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Abstract

Purpose of Review

This review intends to give an up-to-date overview of the current state of evidence in the treatment of coronary artery disease (CAD) in patients undergoing transcatheter aortic valve replacement (TAVR), focusing on percutaneous coronary interventions (PCI) pre-TAVR.

Recent Findings

The recently published ACTIVATION trial is the 1st randomized trial comparing coronary revascularization (PCI) versus medical treatment in patients with significant CAD undergoing TAVR. With the caveat of several major limitations of the trial, the results of this study raised the question about the appropriateness of the common practice to routinely revascularize coronary stenosis before TAVR.

Summary

Aortic valve stenosis is the most common valvular heart disease among the elderly and it often co-occurs with CAD. TAVR is increasingly considered an alternative to surgical aortic valve replacement not only in the elderly population but also in younger and lower-risk patients. The impact of co-existing CAD on clinical outcomes as well as the optimal timing of PCI in TAVR candidates is still unclear and the subject of ongoing randomized trials. Meanwhile, it is common practice in many centers to routinely perform invasive coronary angiography and PCI for significant coronary disease as part of the TAVR workup. While computed tomography angiography has emerged as a possible alternative to the invasive coronary angiography in patients with low pre-test probability for CAD, the value of functional invasive assessment of coronary lesions in the pre-TAVR setting has still to be clarified. Also, there is an increasing interest in the clinical relevance and optimal management of the potentially challenging coronary access post-TAVR, requiring further research.

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Abbreviations

ACS:

Acute coronary syndrome

CABG:

Coronary artery bypass grafting

CAD:

Coronary artery disease

CCS:

Canadian cardiovascular society

cCT:

Coronary computed tomography

CTA:

Computed tomography angiography

FFR:

Fractional flow reserve

iFR:

Instantaneous wave-free ratio

LAD:

Left anterior descending artery

NSTEMI:

Non-ST-elevation myocardial infarction

MACCE:

Major adverse cardiac and cerebrovascular events

PCI:

Percutaneous coronary intervention

rSS:

Residual Syntax Score

SAVR:

Surgical aortic valve replacement

STEMI:

ST-elevation myocardial infarction

SYNTAX:

Synergy Between PCI With Taxus and Cardiac Surgery

TAVR:

Transcatheter aortic valve replacement

References

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

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Acknowledgements

Dr. Rodés-Cabau holds the Research Chair “Fondation Famille Jacques Larivière” for the Development of Structural Heart Interventions. Dr. Keller has received a research grant from “KK Stiftung für Kardiologie und Kreislauf” (Switzerland). Dr. Panagides has received a research grant from the “Mediterranean Academic Research and Studies in Cardiology Association” (MARS Cardio). Dr. Mesnier reports a research grant from “Federation Française de Cardiologie”. Dr. Nuche has received a research grant from the “Fundación Alfonso Martín Escudero” (Madrid, Spain).

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  1. Québec Heart and Lung Institute, Laval University, 2725 Chemin Ste-Foy, Québec City, Québec, G1V 4G5, Canada

    Lukas S. Keller, Vassili Panagides, Jules Mesnier, Jorge Nuche & Josep Rodés-Cabau

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Dr. Rodés-Cabau has received institutional research grants and speaker fees from Edwards Lifesciences and Medtronic. Dr. Panagides has received institutional research grants from Medtronic, Boston scientific and Microport.

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Keller, L.S., Panagides, V., Mesnier, J. et al. Percutaneous Coronary Intervention Pre-TAVR: Current State of the Evidence. Curr Cardiol Rep 24, 1011–1020 (2022). https://doi.org/10.1007/s11886-022-01717-1

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