Abstract 14527: Utility of Routine Invasive Coronary Angiography Prior to Transcatheter Aortic Valve Replacement

Introduction: Despite the high prevalence of CAD in patients with severe aortic stenosis (AS), the optimal management of concomitant coronary artery disease (CAD) before trasncatheter aortic valve replacement (TAVR) remains controversial. Hypothesis: To characterize the contemporary, real-world burden of CAD in contemporary TAVR patients and to evaluate revascularization practices at a high-volume center in the United States. Methods: Analysis of all adult patients referred for TAVR at our center between January 2019 and January 2020. Presence of significant coronary artery disease (stenosis >50%) and subsequent management (medical therapy versus revascularization) were recorded. Presenting symptoms, use of non-invasive and invasive ischemia testing and pre-TAVR computed tomography (CT) imaging were all analyzed. Results: A total of 394 patients with severe AS were referred to our institution for TAVR. Thirty-nine patients (9.9%) instead underwent surgical aortic valve replacement (SAVR), of which only 5 (1.3%) underwent SAVR plus coronary artery bypass surgery. Of the remaining 355 patients (77.3 ± 9.3 years old and 59.7% males), 218 patients (61.4%) had insignificant CAD. Of the 137 patients (38.6%) with significant CAD, only 30 (8.5%) underwent percutaneous coronary intervention (PCI). Of these, less than half had anginal symptoms, a third had CAD in proximal segments and a third underwent ischemia testing prior to PCI. Pre-TAVR CT accurately identified significant CAD in 28/30 patients (93.3%) who ultimately underwent PCI. Conclusions: Only 1 in 25 contemporary TAVR patients had significant CAD and anginal symptoms requiring intervention, questioning the utility of routine invasive coronary angiography before TAVR. A Heart Team approach integrating anginal symptoms and ischemia testing is needed to guide the need, timing and strategy of revascularization. The pre-TAVR CT images could identify significant proximal segment CAD needing PCI.

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Use and outcomes of emergency treatment strategies in patients with aortic valve stenosis

European Heart Journal ◽

10.1093/ehjci/ehaa946.2598 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

S.M Piepenburg ◽

K Kaier ◽

C Olivier ◽

M Zehender ◽

C Bode ◽

...

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Hospital Mortality ◽

Valve Replacement ◽

Aortic Valve Stenosis ◽

Emergency Treatment ◽

Funding Source ◽

Artery Disease

Abstract Introduction and aim Current emergency treatment options for severe aortic valve stenosis include surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR) and balloon valvuloplasty (BV). So far no larger patient population has been evaluated regarding clinical characteristics and outcomes. Therefore we aimed to describe the use and outcome of the three therapy options in a broad registry study. Method and results Using German nationwide electronic health records, we evaluated emergency admissions of symptomatic patients with severe aortic valve stenosis between 2014 and 2017. Patients were grouped according to SAVR, TAVR or BV only treatments. Primary outcome was in-hospital mortality. Secondary outcomes were stroke, acute kidney injury, periprocedural pacemaker implantation, delirium and prolonged mechanical ventilation >48 hours. Stepwise multivariable logistic regression analyses including baseline characteristics were performed to assess outcome risks. 8,651 patients with emergency admission for severe aortic valve stenosis were identified. The median age was 79 years and comorbidities included NYHA classes III-IV (52%), coronary artery disease (50%), atrial fibrillation (41%) and diabetes mellitus (33%). Overall in-hospital mortality was 6.2% during a mean length of stay of 22±15 days. TAVR was the most common treatment (6,357 [73.5%]), followed by SAVR (1,557 [18%]) and BV (737 8.5%]). Patients who were treated with TAVR or BV were significantly older than patients with SAVR (mean age 81.3±6.5 and 81.2±6.9 versus 67.2±11.0 years, p<0.001), had more relevant comorbidities (coronary artery disease 52–91% vs. 21.8%; p<0.001), worse NYHA classes III-IV (55–65% vs. 34.5%; p<0.001) and higher EuroSCORES (24.6±14.3 and 23.4±13.9 vs. 9.5±7.6; p<0.001) than SAVR patients. Patients treated with BV only had the highest in-hospital mortality compared with TAVR or SAVR (20.9% vs. 5.1 and 3.5%; p<0.001). Compared with BV only, SAVR patients (adjusted odds ratio [aOR] 0.25; 95% confidence interval [CI] 0.14–0.46; p<0.001) and TAVR patients (aOR 0.37; 95% CI 0.28–0.50; p<0.001) had a lower risk for in-hospital mortality. Conclusion In-hospital mortality for emergency patients with symptomatic severe aortic valve stenosis is high. Our results showed that BV only therapy was associated with highest mortality, which is in line with current research. Yet, there is a trend towards more TAVR interventions and this study might imply that balloon valvuloplasty alone is insufficient. The role of BV as a bridging strategy to TAVR or SAVR needs to be further investigated. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany

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Use of extracorporeal membrane oxygenation as a bridge to transcatheter aortic valve replacement in a patient with aortic stenosis and severe coronary artery disease: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa567 ◽

2021 ◽

Vol 5 (1) ◽

Author(s):

Majid Ahsan ◽

Rolf Alexander Jánosi ◽

Tienush Rassaf ◽

Alexander Lind

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

High Risk ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Transcatheter Aortic Valve ◽

Risk Patients ◽

Artery Disease

Abstract Background Patients with severe aortic stenosis (AS) often present with multiple comorbidities and suffer from critical coronary artery disease (CAD). Transcatheter aortic valve replacement (TAVR) has become the therapy of choice for moderate to high-risk patients. Venoarterial extracorporeal membrane oxygenation (v-a-ECMO) offers the possibility of temporary cardiac support to manage life-threatening critical situations. Case summary Here, we describe the management of a patient with severe AS and CAD with impaired left ventricular ejection fraction (LVEF). We used v-a-ECMO as an emergency strategy in cardiogenic shock during a high-risk coronary intervention to stabilize the patient, and as a further bridge to TAVR. Discussion Very high-risk patients with severe AS are unlikely to tolerate the added risk of surgical aortic valve replacement. Using ECMO may help them to benefit from TAVR as the only treatment option available.

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