Transcatheter Aortic Valve Replacement With Percutaneous Coronary Intervention: Results From A Federal Facility
Ramon Riojas, Aaron Grober, Kendrick Shunk, Jeffrey Zimmet, Liang Ge, Elaine Tseng.
University of California San Francisco and SFVA Medical Center, San Francisco, CA, USA.
BACKGROUND: Transcatheter aortic valve replacement (TAVR) is the predominant treatment for severe aortic stenosis patients of any surgical risk. Randomized clinical trials addressed isolated aortic stenosis treated by TAVR vs surgical aortic valve replacement (SAVR). However, patients with significant coronary artery disease are recommended for SAVR and coronary artery bypass grafting (CABG) over TAVR and percutaneous coronary intervention (PCI). We examined the outcomes of the subset of patients who underwent TAVR/PCI at a federal facility. Limited TAVR/PCI data is available from VAMC. Using Valve Academic Research Consortium-3 (VARC-3) consensus statements, our objective was to evaluate outcomes of TAVR/PCI at a VA facility. METHODS: As the 4th VAMC approved for TAVR, we retrospectively evaluated 335 TAVR patients since November 2013 for concomitant TAVR/PCI vs staged PCI. Standardized criteria of TAVR outcomes were used from VARC-3. RESULTS: 335 patients (age 78.0±8.5 years) underwent TAVR with 82 self-expanding, and 253 balloon-expandable devices implanted. Overall device success was 97.6%.Eleven patients had planned PCI. Two patients had PCI prior to TAVR, one PCI of 99% Ramus and the other PCI of LAD, LADD, and LCX on CPB support prior to TAVR. Nine patients had simultaneous TAVR/PCI. Two TAVR/PCI had planned CPB support, one with PCI of LM and LCX, the other with PCI of RCA, LCX, and LM. Two TAVR/PCI patients had CPB cannulation but did not require support for PCI LM and other with PCI LM and LAD. Simulataneous PCI/TAVR without planned CPB support included 3 patients, one for PCI LAD, one for PCI anomalous LCX, and one for PCI RCA. One patient had PCI LM post TAVR as a snorkel due to concern with LM obstruction after Valve-in-valve implantation. There was no 30 day mortality after TAVR/PCI. CONCLUSIONS:
We demonstrated excellent TAVR/PCI outcomes at a VA facility in patients with significant coronary artery disease, who underwent staged PCI prior to TAVR and simultaneous TAVR/PCI. Complex TAVR/PCI of LM and multivessel disease was safely performed and facilitated by cannulation for CPB. Further follow-up and understanding of the nuances of CAD treatment with TAVR will be essential for informing choices of TAVR/PCI vs SAVR/CABG.
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