Coronary Revascularization and TAVR Pichard, MD Director Cath Labs, Washington Hospital Center. Professor of Medicine (Cardiology), Georgetown University. Washington, DC.

Conflict of Interest Proctor for Edwards LifeSciences.

Do nothing, proceed with TAVR Revascularize a few weeks before TAVR What should we do with severe coronary obstructions in patients selected for TAVR? Do nothing, proceed with TAVR Revascularize a few weeks before TAVR Revascularize during or after TAVR

CAD in Patients with Severe AS. WHC: Ben-Dor et al CAD in Patients with Severe AS. WHC: Ben-Dor et al. Circulation 2010;122:S37-42 n= 302 patients referred to Partner Trial Patients with CAD had: higher STS and Euro scores, more females, more PVD, lower EF (all significant).

The Surgeons Experience with AVR and CAD

Mortality for AVR. STS Executive Summary 2010 www.sts.org <10% of patients had STS >10

Operative Mortality of AVR in 322 Patients >80 y. o Operative Mortality of AVR in 322 Patients >80 y.o. Gehlot et al, JThorCVSurgery 1996;111:1026-36

278 patients >80 years old discharged after AVR AVR + CABG Surviving Surgery. Gehlot et al, JThorCVSurgery 1996;111:1026-36 278 patients >80 years old discharged after AVR

Hybrid PCI and AVR. Byrne, Cohn et al Hybrid PCI and AVR. Byrne, Cohn et al. JACC 2005;45:14-18, AJC 2006;98:1501 PCI followed by minimally invasive AVR (the same day or within 14 days). 26 high risk patients

Conclusions from the Surgical Series Patients with severe CAD, that jeopardize significant amount of myocardium, need revascularization before or during AVR.

ESC Guidelines of The Task Force on VHD. Vahanian et al ESC Guidelines of The Task Force on VHD. Vahanian et al. EHJ 2007;28:230-267 In patients with severe AS and severe CAD, AVR with concomitant CABG provides a lower mortality. However, combined surgery carries a higher risk than isolated valve replacement in patients without CAD. Thus, CABG should be combined whenever possible with valve surgery. 

CAD and TAVR

CAD and TAVI Outcome Masson, Webb et al. CCI 2010;76:165-73 136 patients with TAVI followed for 1 year. 104 patients (76.5%) had CAD. 15 had PCI 30-100 days prior to TAVI. None had early mortality. Complete or incomplete revascularization did not change outcome. 30 day mortality 6.3% (no CAD) and 11.5% (yes CAD), p=ns. No difference in LV improvement, MR decrease of NYHA class.

CAD and TAVI Outcome Masson, Webb et al. CCI 2010; 76:165-73 These data suggest that short term outcome is not altered by underlying CAD

TAVI and CAD Masson, Webb et al. CCI 2010;76:165-73 Conclusion: The presence of CAD or nonrevascularized myocardium was not associated with an increased risk of adverse events. Complete revascularization may not constitute a prerequisite of TAVI.

CAD and TAVR Dewey et al. Ann Thor Surg g 2010;89:758-67 171 patients enrolled in the TAVR Partner Trial

CAD and TAVR Dewey et al. Ann Thor Surg g 2010;89:758-67 TF

CAD and TAVR Dewey et al. Ann Thor Surg g 2010;89:758-67 Patients with CAD constitute a higher-risk cohort: - higher logistic EuroSCOREs, - lower EF, - larger LV end diastolic volumes, - more significant mitral regurgitation. - more strokes (increase atherosclerotic burden?) Deaths: 11/12 30-day deaths were in patients with CAD. TA group: no 30 d death in patients without CAD.

Coronary Revascularization preparing for TAVI

CAD and TAVI. Gautier et al. Eurointerv 2011;7:549-55 230 patients with TAVI: 63% had CAD CAD patients had higher risk: Euroscore 31 vs 23%. More carotid stenosis 34 vs 9% >2 comorbidities 70 vs 50% 67 patients with 1 or more CAD: 11 patients had PCI (2 during TAVI). 56 had no revascularization. No periprocedural Q wave MI

Outcome of TAVI and CAD. Gautier et al. EuroInterv 2001;7:549-55 No CAD B. Similar survival and symptomatic status for CAD patients with or without revascularization.

167 with CAD: 59 had PCI (23 staged, 36 concomitant). Coronary Revascularization in TAVI Wenawesser et al. EuroInterv 2011;7:541-8 256 TAVI patients. 167 with CAD: 59 had PCI (23 staged, 36 concomitant).

Complete vs. Incomplete Revascularization No CAD

Coronary Revascularization in TAVI Wenawesser et al Coronary Revascularization in TAVI Wenawesser et al. EuroInterv 2011;7:541-8 Conclusions: Staged or concomitant PCI is feasible and safe in TAVI. Complete or incomplete revascularization of CAD does not appear to alter mid-term survival.

FFR in Severe AS Severe AS with LVH has reduced or “exhausted” coronary vascular reserve. Severe AS often has increased diastolic pressures in the LV. Both conditions could lead to a false negative FFR. Pichard et al. Am J Cardiol 1981; 47:547

How do I look at this data? Stable CAD may do well once the hemodynamic burden of severe AS is removed. Progression of CAD or plaque instability could bring on AMI, angina or SD. Hemodynamic instability (ie., ↓ BP) in the presence of untreated severe CAD may have higher mortality.

Conclusions Major territories of ischemia should be revascularized. It seems prudent and safe to do it in a staged manner. Concomitant TAVR and PCI is possible, but needs further evaluation before widespread recommendation.

The end