Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, Tel Hashomer, Israel.
School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
Clin Res Cardiol. 2024 Jan;113(1):11-17. doi: 10.1007/s00392-023-02175-7. Epub 2023 Mar 30.
Chronic coronary syndrome (CCS) is common among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Current guidelines recommend performance of percutaneous coronary intervention (PCI) of any > 70% proximal coronary lesions prior to TAVI.
To evaluate the outcomes of two diagnostic approaches for CCS clearance pre-TAVI and to determine the reduction in the need of invasive angiography (IA).
We investigated 2219 patients undergoing TAVI for severe aortic stenosis at two large centers with different pre-procedural strategies for CCS assessment: pre-TAVI computed tomography angiography (CTA) with selective invasive angiography according to CTA results or mandatory IA. We preformed propensity score matching analysis using a 1:1 ratio. The final study cohort included 870 matched patients. Peri-procedural complications were documented according to the VARC-2 criteria. Mortality rates were prospectively documented.
Mean age of the study population was 82 ± 7, of whom 55% were female. Patients in the IA group had significantly higher rates of pre-TAVI PCI compared to the CTA group (39% vs. 22%, p < 0.001). Following TAVI, peri-procedural myocardial infarction (MI) rates were similar between the two groups (0.3% vs. 0.7%, p value = 0.41), but spontaneous MI were significantly lower among the IA group (0% vs. 1.3%, p value = 0.03). Kaplan-Meier's survival analysis found that the cumulative probability of 1-year morality was similar between the two groups (p value log rank = 0.65). Cox regression analysis did not find association between CCS clearance strategy and outcome.
In elderly patients, CTA-driven approach for CCS evaluation pre-TAVI is a valid strategy with similar outcome as compared to invasive approach. CTA strategy significantly reduces invasive procedures rates without compromising patient's outcome.
慢性冠状动脉综合征（CCS）在接受经导管主动脉瓣植入术（TAVI）的老年严重主动脉瓣狭窄患者中很常见。目前的指南建议在 TAVI 之前对任何 > 70%的近端冠状动脉病变进行经皮冠状动脉介入治疗（PCI）。
评估 TAVI 前两种用于清除 CCS 的诊断方法的结果，并确定减少侵入性血管造影（IA）的需求。
我们调查了在两个大型中心接受 TAVI 治疗严重主动脉瓣狭窄的 2219 名患者，这些中心有不同的 CCS 评估前程序策略：根据 CTA 结果选择性进行 TAVI 前计算机断层扫描血管造影（CTA）和有创血管造影或强制性 IA。我们使用 1:1 比例进行倾向评分匹配分析。最终研究队列包括 870 例匹配患者。根据 VARC-2 标准记录围手术期并发症。前瞻性记录死亡率。
研究人群的平均年龄为 82±7 岁，其中 55%为女性。IA 组患者在 TAVI 前 PCI 的比例明显高于 CTA 组（39% vs. 22%，p<0.001）。TAVI 后，两组间围手术期心肌梗死（MI）发生率相似（0.3% vs. 0.7%，p 值=0.41），但 IA 组自发性 MI 明显较低（0% vs. 1.3%，p 值=0.03）。Kaplan-Meier 生存分析发现两组间 1 年死亡率的累积概率相似（p 值对数秩=0.65）。Cox 回归分析未发现 CCS 清除策略与结果之间存在关联。
在老年患者中，TAVI 前 CTA 驱动的 CCS 评估策略与有创方法相比是一种有效的策略，结果相似。CTA 策略可显著降低侵入性程序的发生率，同时不影响患者的结果。
