Unplanned percutaneous coronary intervention (PCI) after transcatheter aortic valve replacement (TAVR) is rare, with incidence declining over time, according to findings from the international REVIVAL registry released Monday.
The study, which appears in the Jan. 25 issue of JACC: Cardiovascular Interventions, also found that the main indication for PCI after TAVR is acute coronary syndrome, followed by chronic coronary syndromes, and that PCI was frequently successful without any difference between patients whose TAVRs involved balloon-expandable or self-expandable bioprostheses.
Coronary artery disease (CAD) and aortic stenosis frequently coexist. As a result of the growing number of TAVR procedures, the number of patients who may require PCI thereafter is expected to increase in the upcoming years. However, the optimal management of CAD following TAVR remains incompletely elucidated.
Giulio G. Stefanini, MD, PhD, of Humanitas Clinical and Research Center IRCCS, Rozzano – Milan, and co-investigators, sought to evaluate the incidence and causes of PCI at different time periods following TAVR.
The REVIVAL (REVascularization after Implantation of transcatheter aortic VALve bioprosthesis) registry is an international multicenter registry that included all cases of unplanned PCI following TAVR in 20 European centers from July 2008 through March 2019. Patients who underwent a PCI that was planned at the time of TAVR were excluded.
A total of 133 patients (0.9%; from a total cohort of 15,325) underwent unplanned PCI after TAVR (36.1% after balloon-expandable bioprosthesis, 63.9% after self-expandable bioprosthesis). The median time to PCI was 191 days (interquartile range: 59 to 480 days). The daily incidence of PCI was highest during the first week after TAVR and then declined over time.
Overall, the majority of patients underwent PCI due to an acute coronary syndrome. However, chronic coronary syndromes were the main indication beyond 2 years post-TAVR. PCI success was reported in almost all cases (96.6%), with no significant differences between patients treated with balloon-expandable and self-expandable bioprostheses (100% vs. 94.9%; p = 0.150).
There are some limitations to this study. First, because it was retrospective, the analysis lacks a control group. Furthermore, the overall event rate was low; thus, it is difficult to draw conclusions in comparing balloon-expandable valves versus self-expanding valves. Finally, cases of unplanned PCI after TAVR were reported voluntarily by the investigators at each center, with no external monitoring to verify the accuracy of data reported or to exclude the risk of a selection bias.
Despite these limitations, the findings of this study are important. Further studies are needed to define first what optimal management of CAD and aortic stenosis is, then how to deal with coronary revascularization following TAVR, and finally whether there are differences between balloon-expandable and self-expandable bioprostheses.
The study was accompanied by an editorial written by Duk-Woo Park, MD, PhD, and Seung-Jung Park, MD, PhD, of University of Ulsan College of Medicine, Seoul, South Korea. The editorialists congratulated the authors but highlighted the limitations of the study. In addition to the above limitations they stated: “We cannot determine the exact causes or mechanisms of unplanned PCI post-TAVR in this registry (i.e., iatrogenic coronary obstruction, impaired neo-coronary sinus flow, or rapid progression of atherosclerotic plaque). The overall rates of coronary reaccess and PCI success were extremely high in this registry compared with other previous reports (approximately 70%-80%), and the exact reason for such significant heterogeneity among studies is still unknown. This study had a limited follow-up (median time <1 year), and longer time periods may be needed to determine the real impact of CAD on clinical outcomes post-TAVR.“
They concluded by stressing the importance of further studies and stating, “The management of coronary events occurring after TAVR (including coronary access) requires further investigations; more data are urgently needed regarding the coronary access (feasibility and failure rate) across different transcatheter valve types and optimal PCI techniques post-TAVR.”
Stefanini GG, Cerrato E, Pivato CA, et al. Unplanned Percutaneous Coronary Revascularization After TAVR: A Multicenter International Registry. JACC Cardiovasc Interv 2021;14:198–207.
Park D-W, Park S-J. Unplanned Coronary Intervention After TAVR: Timing, Causes, and Management. JACC Cardiovasc Interv 2021;14:208–10.