Huczek Zenon, Zbroński Karol, Grodecki Kajetan, Scisło Piotr, Rymuza Bartosz, Kochman Janusz, Dąbrowski Maciej, Witkowski Adam, Wojakowski Wojciech, Parma Radosław, Ochała Andrzej, Grygier Marek, Olasińska-Wiśniewska Anna, Araszkiewicz Aleksander, Jagielak Dariusz, Ciećwierz Dariusz, Puchta Dominika, Paczwa Katarzyna, Filipiak Krzysztof J, Wilimski Radosław, Zembala Marian, Opolski Grzegorz
First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.
Institute of Cardiology, Warsaw-Anin, Poland.
Catheter Cardiovasc Interv. 2018 Jan 1;91(1):115-123. doi: 10.1002/ccd.27251. Epub 2017 Aug 26.
Coronary artery disease (CAD) and degenerative aortic stenosis often coexist. However, the impact of CAD and its management on the prognosis after transcatheter aortic valve implantation (TAVI) remains uncertain. We sought to evaluate the impact of obstructive CAD, SYNTAX score (Ss), and percutaneous coronary intervention (PCI) prior to TAVI on short-term outcome.
Overall, 896 patients who underwent TAVI after heart team decision was included. Pre-procedural angiograms were analysed to calculate baseline Ss (bSs) and residual Ss (rSs). Baseline, procedural and follow-up data up to 30 days was acquired from the national POL-TAVI registry.
Patients with obstructive CAD at baseline (n = 462, 52%) had higher mortality as compared with the remaining (8.7 vs. 5.1%, log-rank P = 0.039). Also, after correction for confounding factors obstructive CAD was identified as independent predictor of mortality (hazard ratio [HR] 1.74, 95% confidence intervals [CIs] 1.03-2.94, P = 0.037). In obstructive CAD, neither bSs (AUC 0.47, CI 0.38-0.56, P = 0.47) nor rSs (AUC 0.47, CI 0.30-0.64, P = 0.72 for those undergoing PCI and AUC 0.48, CI 0.37-0.59, P = 0.75 for the remaining) was predictive of mortality. When revascularization status was considered, patients with PCI prior to TAVI had similar outcome as those without obstructive CAD at baseline (7.7 vs. 5.1%, log-rank P = 0.23) with no negative impact on mortality (HR 1.13, CI 0.62-2.09, P = 0.69).
In conclusion, obstructive CAD at baseline evaluation for TAVI has independent negative impact on short-term prognosis. However, neither baseline nor residual Ss values have prognostic ability in patients undergoing TAVI. Revascularization prior to TAVI seems to improve survival to levels comparable with patients without obstructive CAD at baseline.
冠状动脉疾病（CAD）与退行性主动脉瓣狭窄常并存。然而，CAD及其治疗对经导管主动脉瓣植入术（TAVI）后预后的影响仍不确定。我们试图评估TAVI术前阻塞性CAD、SYNTAX评分（Ss）和经皮冠状动脉介入治疗（PCI）对短期结局的影响。
总体而言，纳入了896例经心脏团队决策后接受TAVI的患者。分析术前血管造影以计算基线Ss（bSs）和残余Ss（rSs）。从国家POL-TAVI登记处获取基线、手术及直至30天的随访数据。
基线时存在阻塞性CAD的患者（n = 462，52%）与其余患者相比死亡率更高（8.7%对5.1%，对数秩检验P = 0.039）。此外，校正混杂因素后，阻塞性CAD被确定为死亡率的独立预测因素（风险比[HR] 1.74，95%置信区间[CIs] 1.03 - 2.94，P = 0.037）。在阻塞性CAD患者中，bSs（曲线下面积[AUC] 0.47，CI 0.38 - 0.56，P = 0.47）和rSs（接受PCI患者的AUC 0.47，CI 0.30 - 0.64，P = 0.72；其余患者的AUC 0.48，CI 0.37 - 0.59，P = 0.75）均不能预测死亡率。考虑血运重建状态时，TAVI术前接受PCI的患者与基线时无阻塞性CAD的患者结局相似（7.7%对5.1%，对数秩检验P = 0.23），对死亡率无负面影响（HR 1.13，CI 0.62 - 2.09，P = 0.69）。
总之，TAVI基线评估时的阻塞性CAD对短期预后有独立的负面影响。然而，在接受TAVI的患者中，基线和残余Ss值均无预后预测能力。TAVI术前进行血运重建似乎能将生存率提高到与基线时无阻塞性CAD的患者相当的水平。
