Introduction

Rotational atherectomy (RA) has been shown to be safe and effective in patients with severe calcified coronary arteries lesions. However, clinical data on the use of RA in patients with concomitant severe aortic stenosis (AS patients) are lacking. Escalation to RA for coronary lesion preparation in patients undergoing transcatheter aortic valve implantation (TAVI) is still controversial, given their impaired haemodynamic status and possible higher risk of complications. We reported the clinical outcomes of AS patients undergoing RA and TAVI from a prospective clinical registry and compared their outcome with patients undergoing RA with no severe aortic valve stenosis (non-AS patients).
Methods

We retrieved data of all consecutively enrolled patients in The Prospective Segeberg TAVI Registry (ClinicalTrials.gov identifier: NCT03192774) from January 2016 up to October 2021. All AS patients who underwent RA prior to TAVI within a six-month period were included and compared to all patients without severe aortic stenosis (non-AS patients) who underwent RA during the same period. Data were analysed to assess rates of in-hospital major adverse cardiovascular event (MACE) in AS vs non-AS patients. MACE was defined as composite of cardiac death, myocardial infarction, and target lesion revascularisation. Procedural characteristics as well as in-hospital outcomes and complications were also examined to detect differences between both patient groups. We then performed univariate and multivariate analyses using binary logistic regression with the presence of severe aortic stenosis as a dependent variable for MACE.
Results

During the study period, A total of 472 patients underwent RA. Of those, 38 (8.05%) had severe AS and received TAVI within six months after index RA. The mean age of the study population was 76 ± 8.4 years. The AS-patients were older (84.42 ± 6.1 years vs 75.2 ± 8.3; p< 0.001). Most patients were males (60.5% in the AS patients vs 84.6 % in the non-AS patients; p< 0.001). Compared with AS-patients, more non-AS patients presented with acute coronary syndrome (2.6% vs 19.8 %; p<0.009). However, a trend towards more elective RA was seen (78.1% in AS patients vs. 69.3% in non-AS patients, p=0.212). Mechanical circulatory support during the procedures was low (<10 %) in both groups and was used only in two patients from the AS group. Although the used rota burr sizes averaged larger in AS patients, the burr to artery ratio did not differ (0.44 vs 0.43; p=0.174). The procedural duration was less in AS patients with an average of 75 minutes as opposed to an average of 95 minutes in non-AS patients (p<0.016). The procedural success rate was 97% and did not differ between both patients’ groups. 

There was no difference in rates of in-hospital MACE between AS and non-AS patients (7.9% vs 8.8%; p=0.418). Procedural rates of complications related to RA such as slow flow, coronary dissection, coronary perforation, or trapped burr did not differ between both patient groups. Adverse outcomes of RA were not affected by the presence of severe AS in the univariate analysis (OR 1.12; 95% CI [0.33-3.91]; p=0.857).
Conclusion

RA in patients with severe AS undergoing TAVI is feasible with comparable in hospital adverse events to non-AS patients. Adequate lesion preparation of calcified coronary arteries should be implemented regardless of the presence of severe aortic stenosis.