Evaluation of coronary disease among patients undergoing transcatheter aortic valve implantation

Background: Coronary artery disease (CAD) is common among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Current guidelines recommend performance of percutaneous coronary intervention (PCI) of any >70% proximal coronary lesions prior to TAVI. The aim of the current study was to evaluate two approaches to CAD diagnosis pre-TAVI.

Methods: We investigated 2,219 patients undergoing TAVI for severe aortic stenosis at two large centers with different pre-procedural strategies for CAD assessment: pre-TAVI computed tomography angiography (CTA) with selective invasive angiography according to CTA results (N=655) or mandatory invasive angiography (IA) (N=1,564). Peri-procedural complications were documented according to the VARC-2 criteria. Mortality rates were prospectively documented.

Results: Mean age of the study population was 82±7, of whom 53% were female. Patients in the IA group had significantly higher rates of pre-TAVI PCI compared to the CTA group (27% vs. 15%, p<0.001). Following TAVI, peri-procedural myocardial infarction (MI) rates were similar between the two groups (0% vs. 0.8%, p-value=0.183), but spontaneous MI were significantly lower among the IA group (0% vs. 0.8%, p-value<0.001). Kaplan-Meier’s survival analysis found that the cumulative probability of 1-year morality was similar between the two groups (p-value log rank=0.529). Multivariate cox regression adjusted for age, gender and cardiovascular risk factors did not find association between CAD clearance strategy and outcome.

Conclusions: In elderly patients, CTA driven approach for CAD evaluation pre-TAVI is a valid strategy with similar outcome as compared to invasive approach. CTA strategy significantly reduces invasive procedures rates without compromising patient’s outcome.