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Assessment, treatment, and prognostic implications of CAD in patients undergoing TAVI

Key Points

  • The true incidence of obstructive coronary artery disease (CAD) among patients undergoing transcatheter aortic valve implantation (TAVI) is not known

  • Assessment of CAD using angiography only can overestimate the presence of myocardial ischaemia in patients before TAVI

  • Anatomical scoring criteria for CAD can improve the selection of high-risk patients undergoing TAVI

  • Coronary pressure-wire measurements using conventional algorithms before TAVI might underestimate myocardial ischaemia

  • Noninvasive stress testing can be used safely in patients before TAVI, but might overestimate myocardial ischaemia

  • Percutaneous coronary intervention after TAVI is still not widely practised, and only case reports are available

Abstract

Coronary artery disease (CAD) is common in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), but its clinical relevance is controversial. At present, the optimal means of defining CAD in patients undergoing TAVI with respect to its prognostic implications and the assessment of myocardial ischaemia is not known. For this reason, the best treatment options are a matter for debate, and current guidelines do not recommend revascularization. As the indications for TAVI expand, the lack of any rigorous means of guiding coronary revascularization might negatively affect the clinical outcomes of future patients. In this Review, we summarize the methods of assessing CAD in TAVI populations, and the data on the safety and efficacy of percutaneous coronary intervention in patients undergoing TAVI. We discuss the putative effects of aortic stenosis on the functional assessment of CAD using pressure or flow wires or by noninvasive stress testing. We propose that a new, well-validated method of assessing CAD as a cause of myocardial ischaemia — which distinguishes it from myocardial infarction, previous revascularization, or non-flow-limiting disease — in patients with severe aortic stenosis is needed to guide revascularization in the current era of TAVI.

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Figure 1: Putative factors that might influence coronary pressure or flow measurements in the presence of severe aortic stenosis in patients undergoing TAVI.
Figure 2: Representative coronary pressure and flow traces throughout the cardiac cycle before and after TAVI46,49,50.

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E.D., P.H., and R.B. researched data for the article and wrote the manuscript. All the authors contributed substantially to discussion of content, and reviewing and editing the manuscript before submission.

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Correspondence to Edward Danson.

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I.M. receives consulting fees from Boston Scientific. The other authors declare no competing interests.

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Danson, E., Hansen, P., Sen, S. et al. Assessment, treatment, and prognostic implications of CAD in patients undergoing TAVI. Nat Rev Cardiol 13, 276–285 (2016). https://doi.org/10.1038/nrcardio.2016.9

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