Shah Khanjan B, O'Donnell Colin, Mahtta Dhruv, Waldo Stephen W, Choi Calvin, Park Ki, Denktas Ali E, Paniagua David, Khalid Umair
Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida.
Malcolm Randall VA Medical Center, Gainesville, Florida.
J Soc Cardiovasc Angiogr Interv. 2023 Jun 27;2(5):101056. doi: 10.1016/j.jscai.2023.101056. eCollection 2023 Sep-Oct.
Obstructive coronary artery disease (CAD) is common in patients with severe symptomatic aortic stenosis. The management and impact of obstructive CAD in patients undergoing transcatheter aortic valve replacement (TAVR) have not been fully evaluated. We aimed to determine the patient characteristics and clinical outcomes among veterans undergoing TAVR with and without obstructive CAD and to determine temporal trends and association of pre-TAVR percutaneous coronary intervention (PCI) with clinical outcomes.
We identified all patients who underwent TAVR from 2012 to 2021 in the VA Health Care System. The sample population was divided into patients with and without obstructive CAD and further stratified by coronary intervention status 1 year prior to TAVR. The primary outcome was 1-year all-cause mortality, and the secondary outcome was major bleeding.
During the study period, 759 patients underwent TAVR, and 282 (37%) had obstructive CAD. Obstructive CAD was associated with higher 1-year mortality (15.6% vs 7.1%; < .01) after TAVR. The rate of PCI prior to TAVR increased from 2012 until 2016, after which it steadily declined such that 144 patients (51%) underwent PCI pre-TAVR during the entire study period. There was no difference in 1-year mortality (16.0% vs 15.2%; = .89) or bleeding (16.7% vs 12.3%; = .33) between patients who underwent or did not undergo pre-TAVR PCI.
Among veterans undergoing TAVR, the presence of obstructive CAD is associated with higher mortality though pre-TAVR coronary intervention is not associated with improved outcomes. Further studies could identify a subset of patients who may benefit from coronary revascularization prior to TAVR.
阻塞性冠状动脉疾病（CAD）在有严重症状性主动脉瓣狭窄的患者中很常见。经导管主动脉瓣置换术（TAVR）患者中阻塞性CAD的管理及影响尚未得到充分评估。我们旨在确定有和没有阻塞性CAD的退伍军人接受TAVR后的患者特征和临床结局，并确定TAVR前经皮冠状动脉介入治疗（PCI）的时间趋势及其与临床结局的关联。
我们识别了2012年至2021年在退伍军人事务部（VA）医疗保健系统中接受TAVR的所有患者。样本人群分为有和没有阻塞性CAD的患者，并根据TAVR前1年的冠状动脉介入治疗状态进一步分层。主要结局是1年全因死亡率，次要结局是大出血。
在研究期间，759例患者接受了TAVR，其中282例（37%）有阻塞性CAD。阻塞性CAD与TAVR后较高的1年死亡率相关（15.6%对7.1%；P<0.01）。TAVR前PCI的发生率从2012年至2016年上升，此后稳步下降，以至于在整个研究期间有144例患者（51%）在TAVR前接受了PCI。接受或未接受TAVR前PCI的患者在1年死亡率（16.0%对15.2%；P=0.89）或出血（16.7%对12.3%；P=0.33）方面没有差异。
在接受TAVR的退伍军人中，阻塞性CAD的存在与较高死亡率相关，尽管TAVR前冠状动脉介入治疗与改善结局无关。进一步的研究可以确定可能从TAVR前冠状动脉血运重建中获益的患者亚组。
