St George's University Hospitals NHS Foundation Trust, Blackshaw Road, Tooting, London SW17 0QT, UK.
Royal North Shore Hospital, Reserve Road, St Leonard's, New South Wales 2065, Australia.
Nat Rev Cardiol. 2016 May;13(5):276-85. doi: 10.1038/nrcardio.2016.9. Epub 2016 Feb 11.
Coronary artery disease (CAD) is common in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), but its clinical relevance is controversial. At present, the optimal means of defining CAD in patients undergoing TAVI with respect to its prognostic implications and the assessment of myocardial ischaemia is not known. For this reason, the best treatment options are a matter for debate, and current guidelines do not recommend revascularization. As the indications for TAVI expand, the lack of any rigorous means of guiding coronary revascularization might negatively affect the clinical outcomes of future patients. In this Review, we summarize the methods of assessing CAD in TAVI populations, and the data on the safety and efficacy of percutaneous coronary intervention in patients undergoing TAVI. We discuss the putative effects of aortic stenosis on the functional assessment of CAD using pressure or flow wires or by noninvasive stress testing. We propose that a new, well-validated method of assessing CAD as a cause of myocardial ischaemia--which distinguishes it from myocardial infarction, previous revascularization, or non-flow-limiting disease--in patients with severe aortic stenosis is needed to guide revascularization in the current era of TAVI.
冠状动脉疾病(CAD)在接受经导管主动脉瓣置换术(TAVI)的严重主动脉瓣狭窄患者中很常见,但其临床相关性存在争议。目前,对于 TAVI 患者,关于 CAD 的预后意义和心肌缺血评估,尚不清楚最佳的定义方法。出于这个原因,最佳的治疗选择存在争议,目前的指南不建议进行血运重建。随着 TAVI 适应证的扩大,缺乏任何严格的冠状动脉血运重建指导方法,可能会对未来患者的临床结局产生负面影响。在这篇综述中,我们总结了评估 TAVI 人群中 CAD 的方法,以及经皮冠状动脉介入治疗在接受 TAVI 患者中的安全性和疗效数据。我们讨论了使用压力或血流导丝或无创应激测试时,主动脉瓣狭窄对 CAD 功能性评估的潜在影响。我们提出,需要一种新的、经过充分验证的方法来评估严重主动脉瓣狭窄患者的 CAD 作为心肌缺血的原因,以区分其与心肌梗死、先前的血运重建或非血流限制性疾病,从而指导当前 TAVI 时代的血运重建。