Abstract
Purpose of Review
To summarize epidemiology, pathophysiology, prognostic relevance, and treatment options of coronary artery disease (CAD) when coupled with severe aortic stenosis (SAS). In regard to treatment options, we focused on the most recently adopted therapeutic approaches and on the future perspectives in light of the latest percutaneous and surgical technical improvements in the field of both CAD and SAS management.
Recent Findings
Nowadays, SAS is the most common valve disease requiring intervention, either surgical or percutaneous. On the other side, CAD is one of the leading causes of death in the developed countries. CAD and degenerative SAS share several predisposing factors and are often concurrently found in clinical practice. Despite in the last years the transcatheter aortic valve replacement (TAVR) has been deeply changing the therapeutic approach to SAS, the correct management of patients with concomitant CAD remains controversial due to limited and heterogeneous data in the literature.
Summary
Coronary revascularization is often performed in patients with concomitant CAD and SAS. Complete surgical approach is still the standard of care according to international guidelines. However, in light of the recent results of TAVR trials, the therapeutic approach is expected to change. To date, percutaneous coronary intervention performed before TAVR is safe and feasible even if the optimal timing for revascularization remains debated. Due to the great complexity of the patients affected by SAS and CAD and until unquestionable truths will come from large randomized trials, the role of the Heart Team in the decision-making process is of primary importance to guarantee the best tailored therapeutic strategy for the single patient.
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References
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Stewart BF, Siscovick D, Lind BK, Gardin JM, Gottdiener JS, Smith VE, et al. Clinical factors associated with calcific aortic valve disease. Cardiovascular health study. J Am Coll Cardiol. 1997;29(3):630–4.
Cao D, Chiarito M, Pagnotta P, Reimers B, Stefanini GG. Coronary revascularisation in transcatheter aortic valve implantation candidates: why, who, when? Interv Cardiol. 2018;13(2):69–76.
Rapp AH, Hillis LD, Lange RA, Cigarroa JE. Prevalence of coronary artery disease in patients with aortic stenosis with and without angina pectoris. Am J Cardiol. 2001;87(10):1216–7 A7.
Exadactylos N, Sugrue DD, Oakley CM. Prevalence of coronary artery disease in patients with isolated aortic valve stenosis. Br Heart J. 1984;51(2):121–4.
Kvidal P, Bergström R, Hörte LG, Ståhle E. Observed and relative survival after aortic valve replacement. J Am Coll Cardiol. 2000;35(3):747–56.
Gilbert T, Orr W, Banning AP. Surgery for aortic stenosis in severely symptomatic patients older than 80 years: experience in a single UK centre. Heart. 1999;82(2):138–42.
Akins CW, Daggett WM, Vlahakes GJ, Hilgenberg AD, Torchiana DF, Madsen JC, et al. Cardiac operations in patients 80 years old and older. Ann Thorac Surg. 1997;64(3):606–14 discussion 614-5.
Goel SS, Ige M, Tuzcu EM, Ellis SG, Stewart WJ, Svensson LG, et al. Severe aortic stenosis and coronary artery disease--implications for management in the transcatheter aortic valve replacement era: a comprehensive review. J Am Coll Cardiol. 2013;62(1):1–10.
•• Faroux L, Guimaraes L, Wintzer-Wehekind J, Junquera L, Ferreira-Neto AN, Del Val D, et al. Coronary artery disease and transcatheter aortic valve replacement: JACC state-of-the-art review. J Am Coll Cardiol. 2019;74(3):362–72. This review provides an updated overview of the current landscape of CAD in TAVR recipients.
Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364(23):2187–98.
Kodali SK, Williams MR, Smith CR, Svensson LG, Webb JG, Makkar RR, et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med. 2012;366(18):1686–95.
Mack MJ, Leon MB, Smith CR, Miller DC, Moses JW, Tuzcu EM, et al. 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet. 2015;385(9986):2477–84.
Adams DH, Popma JJ, Reardon MJ, Yakubov SJ, Coselli JS, Deeb GM, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med. 2014;370(19):1790–8.
Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374(17):1609–20.
Reardon MJ, Van Mieghem NM, Popma JJ, Kleiman NS, Søndergaard L, Mumtaz M, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2017;376(14):1321–31.
Mack MJ, Leon MB, Thourani VH, Makkar R, Kodali SK, Russo M, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med. 2019;380(18):1695–705.
Popma JJ, Deeb GM, Yakubov SJ, Mumtaz M, Gada H, O'Hair D, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med. 2019;380(18):1706–15.
Tamburino C, Barbanti M, D’Errigo P, Ranucci M, Onorati F, Covello RD, et al. 1-year outcomes after transfemoral transcatheter or surgical aortic valve replacement: results from the Italian OBSERVANT study. J Am Coll Cardiol. 2015;66(7):804–12.
Gilard M, Eltchaninoff H, Iung B, Donzeau-Gouge P, Chevreul K, Fajadet J, et al. Registry of transcatheter aortic-valve implantation in high-risk patients. N Engl J Med. 2012;366(18):1705–15.
Ludman PF, Moat N, de Belder MA, Blackman DJ, Duncan A, Banya W, et al. Transcatheter aortic valve implantation in the United Kingdom: temporal trends, predictors of outcome, and 6-year follow-up: a report from the UK Transcatheter Aortic Valve Implantation (TAVI) Registry, 2007 to 2012. Circulation. 2015;131(13):1181–90.
Abdel-Wahab M, Zahn R, Horack M, Gerckens U, Schuler G, Sievert H, et al. Transcatheter aortic valve implantation in patients with and without concomitant coronary artery disease: comparison of characteristics and early outcome in the German multicenter TAVI registry. Clin Res Cardiol. 2012;101(12):973–81.
Holmes DR, Nishimura RA, Grover FL, Brindis RG, Carroll JD, Edwards FH, et al. Annual outcomes with transcatheter valve therapy: from the STS/ACC TVT registry. J Am Coll Cardiol. 2015;66(25):2813–23.
Hamm CW, Möllmann H, Holzhey D, Beckman A, Veit C, Figulla HR, et al. The German aortic valve registry (GARY): in-hospital outcome. Eur Heart J. 2014;35(24):1588–98.
Huczek Z, Zbroński K, Grodecki K, Scisło P, Rymuza B, Kochman J, et al. Concomitant coronary artery disease and its management in patients referred to transcatheter aortic valve implantation: insights from the POL-TAVI Registry. Catheter Cardiovasc Interv. 2018;91(1):115–23.
Otto CM, Kuusisto J, Reichenbach DD, Gown AM, O'Brien KD. Characterization of the early lesion of ‘degenerative’ valvular aortic stenosis. Histological and immunohistochemical studies. Circulation. 1994;90(2):844–53.
O'Brien KD, Kuusisto J, Reichenbach DD, Ferguson M, Giachelli C, Alpers CE, et al. Osteopontin is expressed in human aortic valvular lesions. Circulation. 1995;92(8):2163–8.
Olsson M, Dalsgaard CJ, Haegerstrand A, Rosenqvist M, Rydén L, Nilsson J. Accumulation of T lymphocytes and expression of interleukin-2 receptors in nonrheumatic stenotic aortic valves. J Am Coll Cardiol. 1994;23(5):1162–70.
Fishbein GA, Fishbein MC. Pathology of the aortic valve: aortic valve stenosis/aortic regurgitation. Curr Cardiol Rep. 2019;21(8):81.
Aranki SF, Rizzo RJ, Couper GS, Adams DH, Collins JJ, Gildea JS, et al. Aortic valve replacement in the elderly. Effect of gender and coronary artery disease on operative mortality. Circulation. 1993;88(5 Pt 2):II17–23.
Dewey TM, Brown DL, Herbert MA, Culica D, Smith CR, Leon MB, et al. Effect of concomitant coronary artery disease on procedural and late outcomes of transcatheter aortic valve implantation. Ann Thorac Surg. 2010;89(3):758–67 discussion 767.
Tjang YS, van Hees Y, Körfer R, Grobbee DE, van der Heijden GJ. Predictors of mortality after aortic valve replacement. Eur J Cardiothorac Surg. 2007;32(3):469–74.
Beach JM, Mihaljevic T, Svensson LG, Rajeswaran J, Marwick T, Griffin B, et al. Coronary artery disease and outcomes of aortic valve replacement for severe aortic stenosis. J Am Coll Cardiol. 2013;61(8):837–48.
Gautier M, Pepin M, Himbert D, Ducrocq G, Iung B, Dilly MP, et al. Impact of coronary artery disease on indications for transcatheter aortic valve implantation and on procedural outcomes. EuroIntervention. 2011;7(5):549–55.
D'Ascenzo F, Conrotto F, Giordana F, Moretti C, D'Amico M, Salizzoni S, et al. Mid-term prognostic value of coronary artery disease in patients undergoing transcatheter aortic valve implantation: a meta-analysis of adjusted observational results. Int J Cardiol. 2013;168(3):2528–32.
Witberg G, Regev E, Chen S, Assali A, Barbash IM, Planer D, et al. The prognostic effects of coronary disease severity and completeness of revascularization on mortality in patients undergoing transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2017;10(14):1428–35.
• D'Ascenzo F, Verardi R, Visconti M, Conrotto F, Scacciatella P, Dziewierz A, et al. Independent impact of extent of coronary artery disease and percutaneous revascularization on 30-day and one-year mortality after TAVI: a meta-analysis of adjusted observational results. EuroIntervention. 2018;14(11):e1169–77. An exemplary meta-analysis of the impact of the severity of coronary artery disease and percutaneous coronary interventions on outcomes after transcatheter aortic valve implantation.
Iung B. Interface between valve disease and ischemic heart disease. Heart. 2000;84(3):347–532.
van den Boogert TPW, Vendrik J, Claessen BEPM, Baan J, Beijk MA, Limpens J, et al. 2018. CTCA for detection of significant coronary artery disease in routine TAVI work-up: a systematic review and meta-analysis. Neth Hear J. 2018;26(12):591–9.
Chieffo A, Giustino G, Spagnolo P, Panoulas VF, Montorfano M, Latib A, et al. Routine screening of coronary artery disease with computed tomographic coronary angiography in place of invasive coronary angiography in patients undergoing transcatheter aortic valve replacement. Circ Cardiovasc Interv. 2015;8(7):e002025.
Primary non-invasive cardiac computed tomography versus routine invasive angiography prior to TAVI (CT-CA). https://clinicaltrials.gov/ct2/show/NCT03291925.
Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87–165.
Lund O, Nielsen TT, Pilegaard HK, Magnussen K, Knudsen MA. The influence of coronary artery disease and bypass grafting on early and late survival after valve replacement for aortic stenosis. J Thorac Cardiovasc Surg. 1990;100(3):327–37.
Hannan EL, Wu C, Bennett EV, Carlson RE, Culliford AT, Gold JP, et al. Risk index for predicting in-hospital mortality for cardiac valve surgery. Ann Thorac Surg. 2007;83(3):921–9.
Nowicki ER, Birkmeyer NJ, Weintraub RW, Leavitt BJ, Sanders JH, Dacey LJ, et al. Multivariable prediction of in-hospital mortality associated with aortic and mitral valve surgery in Northern New England. Ann Thorac Surg. 2004;77(6):1966–77.
Bonow RO, Kent KM, Rosing DR, Lipson LC, Borer JS, McIntosh CL, et al. Aortic valve replacement without myocardial revascularization in patients with combined aortic valvular and coronary artery disease. Circulation. 1981;63(2):243–51.
Thalji NM, Suri RM, Daly RC, Greason KL, Dearani JA, Stulak JM, et al. The prognostic impact of concomitant coronary artery bypass grafting during aortic valve surgery: implications for revascularization in the transcatheter era. J Thorac Cardiovasc Surg. 2015b;149(2):451–60.
Sakakura R, Asai T, Suzuki T, Kinoshita T, Enomoto M, Kondo Y, et al. Outcomes after aortic valve replacement for aortic valve stenosis, with or without concomitant coronary artery bypass grafting. Gen Thorac Cardiovasc Surg. 2019;67(6):510–7.
Giordano A, Corcione N, Ferraro P, Morello A, Conte S, Testa L, et al. Comparison of ProGlide vs. Prostar in patients undergoing transcatheter aortic valve implantation. Minerva Cardioangiol. 2019.
Giordano A, Corcione N, Ferraro P, Morello A, Conte S, Testa L, et al. Comparative one-month safety and effectiveness of five leading new-generation devices for transcatheter aortic valve implantation. Sci Rep. 2019;9(1):17098.
Goel SS, Agarwal S, Tuzcu EM, Ellis SG, Svensson LG, Zaman T, et al. Percutaneous coronary intervention in patients with severe aortic stenosis: implications for transcatheter aortic valve replacement. Circulation. 2012;125(8):1005–13.
Paradis JM, White JM, Généreux P, Urena M, Doshi D, Nazif T, et al. Impact of coronary artery disease severity assessed with the SYNTAX score on outcomes following transcatheter aortic valve replacement. J Am Heart Assoc. 2017;6(2).
Van Mieghem NM, van der Boon RM, Faqiri E, Diletti R, Schultz C, van Geuns RJ, et al. Complete revascularization is not a prerequisite for success in current transcatheter aortic valve implantation practice. JACC Cardiovasc Interv. 2013;6(8):867–75.
Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739–91.
Khawaja MZ, Wang D, Pocock S, Redwood SR, Thomas MR. The percutaneous coronary intervention prior to transcatheter aortic valve implantation (ACTIVATION) trial: study protocol for a randomized controlled trial. Trials. 2014;15:300.
Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597–607.
Popma JJ, Adams DH, Reardon MJ, Yakubov SJ, Kleiman NS, Heimansohn D, et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol. 2014;63(19):1972–81.
Barbanti M, Buccheri S, Capodanno D, D'Errigo P, Ranucci M, Rosato S, et al. Transcatheter or surgical treatment of severe aortic stenosis and coronary artery disease: a comparative analysis from the Italian OBSERVANT study. Int J Cardiol. 2018;270:102–6.
Parasca CA, Head SJ, Milojevic M, Mack MJ, Serruys PW, Morice MC, et al. Incidence, characteristics, predictors, and outcomes of repeat revascularization after percutaneous coronary intervention and coronary artery bypass grafting: the SYNTAX trial at 5 years. JACC Cardiovasc Interv. 2016;9(24):2493–507.
Abdel-Wahab M, Mostafa AE, Geist V, Stöcker B, Gordian K, Merten C, et al. Comparison of outcomes in patients having isolated transcatheter aortic valve implantation versus combined with preprocedural percutaneous coronary intervention. Am J Cardiol. 2012;109(4):581–6.
van Rosendael PJ, van der Kley F, Kamperidis V, Katsanos S, Al Amri I, Regeer M, et al. Timing of staged percutaneous coronary intervention before transcatheter aortic valve implantation. Am J Cardiol. 2015;115(12):1726–32.
Perez S, Thielhelm TP, Cohen MG. To revascularize or not before transcatheter aortic valve implantation? J Thorac Dis. 2018;10(Suppl 30):S3578–87.
Wenaweser P, Pilgrim T, Guerios E, Stortecky S, Huber C, Khattab AA, et al. Impact of coronary artery disease and percutaneous coronary intervention on outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation. EuroIntervention. 2011;7(5):541–8.
•• Yudi MB, Sharma SK, Tang GHL, Kini A. Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement. J Am Coll Cardiol. 2018;71(12):1360–78. Brilliant review about the challenges of coronary angiography and percutaneous coronary intervention post-TAVR.
Baumbach H, Schairer ER, Wachter K, Rustenbach C, Ahad S, Stan A, et al. Transcatheter aortic valve replacement- management of patients with significant coronary artery disease undergoing aortic valve interventions: surgical compared to catheter-based approaches in hybrid procedures. BMC Cardiovasc Disord. 2019;19(1):108.
• Pesarini G, Scarsini R, Zivelonghi C, Piccoli A, Gambaro A, Gottin L, et al. Functional assessment of coronary artery disease in patients undergoing transcatheter aortic valve implantation: influence of pressure overload on the evaluation of lesions severity. Circ Cardiovasc Interv. 2016;9(11):e004088. A prospective, observational study investigating whether FFR values might change after valve replacement.
Scarsini R, Pesarini G, Zivelonghi C, Piccoli A, Ferrero V, Lunardi M, et al. Physiologic evaluation of coronary lesions using instantaneous wave-free ratio (iFR) in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation. EuroIntervention. 2018b;13(13):1512–9.
Scarsini R, Pesarini G, Zivelonghi C, Piccoli A, Ferrero V, Lunardi M, et al. Coronary physiology in patients with severe aortic stenosis: comparison between fractional flow reserve and instantaneous wave-free ratio. Int J Cardiol. 2017;243:40–6.
Wiegerinck EM, van de Hoef TP, Rolandi MC, Yong Z, van Kesteren F, Koch KT, et al. Impact of aortic valve stenosis on coronary hemodynamics and the instantaneous effect of transcatheter aortic valve implantation. Circ Cardiovasc Interv. 2015;8(8):e002443.
Scarsini R, Cantone R, Venturi G, De Maria GL, Variola A, Braggio P, et al. Correlation between intracoronary physiology and myocardial perfusion imaging in patients with severe aortic stenosis. Int J Cardiol. 2019;292:162–5.
Scarsini R, Pesarini G, Lunardi M, Piccoli A, Zanetti C, Cantone R, et al. Observations from a real-time, iFR-FFR “hybrid approach” in patients with severe aortic stenosis and coronary artery disease undergoing TAVI. Cardiovasc Revasc Med. 2018a;19(3 Pt B):355–9.
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Pepe, M., Larosa, C., Rosa, I. et al. Degenerative Severe Aortic Stenosis and Concomitant Coronary Artery Disease: What Is Changing in the Era of the “Transcatheter Revolution”?. Curr Atheroscler Rep 22, 17 (2020). https://doi.org/10.1007/s11883-020-0835-1
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DOI: https://doi.org/10.1007/s11883-020-0835-1