Division of Cardiology, Southlake Regional Health Centre, Newmarket.
Division of Cardiology.
Curr Opin Cardiol. 2020 Sep;35(5):540-547. doi: 10.1097/HCO.0000000000000768.
Coronary artery disease (CAD) is commonly observed in patients undergoing transcatheter aortic valve replacement (TAVR). Significant variability exists across institutions for strategies used for CAD diagnosis and its management. The heart team often relies upon traditional practice patterns and the decision for revascularization by percutaneous coronary intervention (PCI) is influenced by patient, angiographic, operator, and system-related factors.
Contemporary coronary tomography angiography (CTA) shows significant promise for detection of clinically important CAD and preliminary data support CTA use for TAVR patients. The prognostic implications of CAD in a TAVR population remain unclear with studies showing conflicting data for the benefits of PCI. Recent trials show that medical management is an effective initial treatment strategy for stable CAD, a finding likely also applicable for asymptomatic and stable TAVR patients. In addition, PCI performed pre-TAVR, concomitant with TAVR or after TAVR has been shown to produce similar outcomes. Dual antiplatelet therapy (DAPT) is mandated after PCI but associated with increased risk of bleeding in TAVR population with accumulating evidence for single antiplatelet therapy (SAPT) post-TAVR unless DAPT or anticoagulation is indicated for another reason.
Although coronary angiography remains the predominant modality for CAD assessment, CTA is increasingly being used in TAVR patients. There is limited evidence to guide CAD management in TAVR patients with significant variability in practice patterns. Medical therapy is recommended for asymptomatic and stable CAD patients with applicability for TAVR population. Despite prior concerns, recent studies suggest successful coronary access post-TAVR and similar outcomes for PCI offered pre-TAVR, concomitant with TAVR and post-TAVR settings. Safety of DAPT should be an important consideration for PCI in TAVR patients. Ongoing studies will determine the preferred testing for CAD diagnosis, benefit of revascularization, timing of PCI, and optimum antithrombotic therapy for TAVR populations.
经导管主动脉瓣置换术（TAVR）患者常合并冠状动脉疾病（CAD）。各医疗机构 CAD 诊断和治疗策略存在显著差异。心脏团队通常依赖传统的治疗模式，经皮冠状动脉介入治疗（PCI）的决策受患者、血管造影、术者和系统相关因素的影响。
当代冠状动脉计算机断层血管造影（CTA）在检测有临床意义的 CAD 方面显示出巨大的潜力，初步数据支持 CTA 在 TAVR 患者中的应用。CAD 在 TAVR 人群中的预后意义尚不清楚，研究表明 PCI 的获益存在矛盾的数据。最近的临床试验表明，对于稳定型 CAD，药物治疗是一种有效的初始治疗策略，这一发现可能也适用于无症状和稳定的 TAVR 患者。此外，TAVR 前、TAVR 同期和 TAVR 后进行 PCI 已被证明可产生相似的结果。PCI 后必须进行双联抗血小板治疗（DAPT），但 TAVR 人群中 DAPT 相关出血风险增加，且有大量证据支持 TAVR 后进行单联抗血小板治疗（SAPT），除非出于其他原因需要 DAPT 或抗凝。
尽管冠状动脉造影仍然是 CAD 评估的主要方式，但 CTA 在 TAVR 患者中的应用越来越广泛。对于 TAVR 患者的 CAD 管理，目前的循证医学证据有限，且实践模式存在很大差异。对于无症状和稳定型 CAD 患者，推荐进行药物治疗，TAVR 人群也适用。尽管存在先前的担忧，但最近的研究表明 TAVR 后可以成功进行冠状动脉介入，且 TAVR 前、同期和后进行 PCI 的效果相似。对于 TAVR 患者，DAPT 的安全性应是 PCI 的一个重要考虑因素。正在进行的研究将确定 TAVR 人群 CAD 诊断的首选检查方法、血运重建的获益、PCI 的时机以及最佳的抗血栓治疗方案。
