Background and aims: 

Coronary artery disease (CAD) is common in patients undergoing transcatheter aortic valve implantation (TAVI). In spite of numerous studies, the impact of pre-TAVI coronary revascularization on early and longer-term outcomes are not yet fully understood. Moreover, it is not known whether a complete revascularization is warranted before TAVI. We sought to investigate the impact of the completeness of percutaneous coronary revascularization on TAVI outcomes. 

 

Methods and results: 

From September 2007 to December 2016, 875 patients underwent TAVI at our institution. Before TAVI, coronary angiography was performed in all patients and significant CAD (at least one stenosis ≥50% in a vessel ≥1.5 mm) was documented in 572 (65.4%) and involved 1 vessel in 169 (29.9%), 2 vessels in 168 (29.7%), and 3 vessels in 229 patients (40.5%). In 300 patients (52.5% of those with CAD), percutaneous coronary intervention (PCI) was scheduled pre-TAVI (within 90 days before the procedure). The SYNTAX (Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score was calculated in all patients with no previous bypass grafting (n=206) - before and after PCI - to assess the SYNTAX Revascularization Index (SRI= % reduction of the SYNTAX score from before to after PCI). PCI that led to an SRI of 100% was considered complete revascularization.

Percutaneous revascularization was complete in 129 patients (62.6%) and incomplete in 77 (37.4%). Compared to patients with incomplete revascularization, those who had a complete revascularization had a lower 30-day all-cause mortality (0.0% vs. 5.2%, p=0.019), cardiovascular mortality (0.0% vs. 3.9%, p=0.050), and major vascular complications (4.7% vs. 14.5%, p=0.018). The rates of 30-day stroke, major and life-threatening bleeding, and acute kidney injury were not different between the two groups. The SRI was higher in patients who survived beyond 30 days post-TAVI than in those who died in the peri-procedural period (82.2±28.1% vs. 44.4±16.1%, p=0.005; OR, 0.968 [95%CI, 0.940-0.996] /1% increment in SRI; p=0.024). 

At one year post-TAVI, all-cause mortality was significantly lower in patients who had a complete percutaneous coronary revascularization (14.1%) than in patients with incomplete revascularization (25.3%; log rank p=0.028; HR, 0.492 [95% CI, 0.258-0.940], p=0.032). Similarly, cardiovascular mortality was higher in the former than in the latter group (7.8% vs. 16.5%, log rank p=0.030; HR, 0.403 [95% CI, 0.172-0.943], p=0.036). The SRI was significantly higher in patients who survived (83.8±26.8%) than in patients who died within 1 year after the procedure (71.9±32.0, p=0.024; HR, 0.989[0.979-0.998] /1% increment of SRI, p=0.017). Cardiovascular mortality was similarly associated with a lower SRI (68.7±35.3% vs. 83,2±26,8%  p=0.036; HR, 0.985 [95% CI, 0.974-0.997]/1% increment of SRI, p=0.014).

 

Conclusions:

The completeness of percutaneous revascularization of significant CAD is a determinant of early and mid-term mortality after TAVI. A higher SRI should be targeted in patients undergoing PCI before TAVI.