Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, United States of America.
Cardiovasc Revasc Med. 2021 May;26:1-5. doi: 10.1016/j.carrev.2020.11.022. Epub 2020 Nov 20.
BACKGROUND/PURPOSE: Despite the high prevalence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS), the optimal management of concomitant CAD, including revascularization before transcatheter aortic valve replacement (TAVR), remains controversial. Contemporary, real-world practice patterns have not yet been described. We aimed to characterize the burden of CAD in contemporary TAVR patients and evaluate revascularization practices at a high-volume center.
METHODS/MATERIALS: We retrospectively analyzed all adult patients referred for TAVR at our center between January 2019 and January 2020. Presence of significant CAD and subsequent management were recorded. Presenting symptoms, use of non-invasive and invasive ischemia testing, and pre-TAVR computed tomography (CT) imaging were analyzed.
A total of 394 patients with severe AS were referred for TAVR. Thirty-nine patients (9.9%) instead underwent surgery, of whom only 5 (1.3%) received coronary artery bypass grafting. Of the remaining 355 patients, 218 patients (61.4%) had insignificant CAD. Of the 137 patients (38.6%) with significant CAD, only 30 (8.5%) underwent percutaneous coronary intervention (PCI). Of these, less than half had anginal symptoms, a third had CAD in proximal segments, and a third underwent ischemia testing before PCI. Pre-TAVR CT accurately identified significant CAD in 28/30 patients (93.3%) who underwent PCI.
Only 1 in 25 contemporary TAVR patients had significant CAD and angina requiring intervention, calling into question the utility of routine invasive coronary angiography before TAVR. A Heart Team approach integrating anginal symptoms, ischemia testing and possibly pre-TAVR CT is needed to guide the need, timing, and strategy of revascularization.
背景/目的：尽管严重主动脉瓣狭窄（AS）患者的冠状动脉疾病（CAD）患病率很高，但 CAD 的最佳治疗方法，包括经导管主动脉瓣置换术（TAVR）前的血运重建，仍存在争议。目前还没有描述当代的真实世界实践模式。我们旨在描述当代 TAVR 患者 CAD 的负担，并评估一个大容量中心的血运重建实践。
方法/材料：我们回顾性分析了我们中心 2019 年 1 月至 2020 年 1 月期间所有接受 TAVR 的成年患者。记录了 CAD 的存在和随后的管理。分析了主要症状、非侵入性和侵入性缺血检测的使用情况以及 TAVR 前 CT 成像。
共 394 例严重 AS 患者接受 TAVR 治疗。39 例（9.9%）患者转而接受手术，其中仅 5 例（1.3%）接受冠状动脉旁路移植术。在其余 355 例患者中，218 例（61.4%）患者 CAD 不显著。在 137 例（38.6%）有明显 CAD 的患者中，仅有 30 例（8.5%）患者接受经皮冠状动脉介入治疗（PCI）。其中，不到一半的患者有胸痛症状，三分之一的患者近端 CAD，三分之一的患者在 PCI 前进行了缺血检测。在接受 PCI 的 30 例患者中（93.3%），TAVR 前 CT 准确地识别出了有意义的 CAD。
只有 1/25 例当代 TAVR 患者有需要介入治疗的明显 CAD 和心绞痛，这使得在 TAVR 前常规进行有创冠状动脉造影的实用性受到质疑。需要一种心脏团队方法，综合考虑胸痛症状、缺血检测，可能还有 TAVR 前 CT，以指导血运重建的必要性、时机和策略。
