Transcatheter Aortic Valve Implantation With or Without Percutaneous Coronary Artery Revascularization Strategy: A Systematic Review and Meta-Analysis

J Am Heart Assoc. 2017 Jun 27;6(6):e005960. doi: 10.1161/JAHA.117.005960.

Abstract

Background: Recent recommendations suggest that in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation and coexistent significant coronary artery disease, the latter should be treated before the index procedure; however, the evidence basis for such an approach remains limited. We performed a systematic review and meta-analysis to study the clinical outcomes of patients with coronary artery disease who did or did not undergo revascularization prior to transcatheter aortic valve implantation.

Methods and results: We conducted a search of Medline and Embase to identify studies evaluating patients who underwent transcatheter aortic valve implantation with or without percutaneous coronary intervention. Random-effects meta-analyses with the inverse variance method were used to estimate the rate and risk of adverse outcomes. Nine studies involving 3858 participants were included in the meta-analysis. Patients who underwent revascularization with percutaneous coronary intervention had a higher rate of major vascular complications (odd ratio [OR]: 1.86; 95% confidence interval [CI], 1.33-2.60; P=0.0003) and higher 30-day mortality (OR: 1.42; 95% CI, 1.08-1.87; P=0.01). There were no differences in effect estimates for 30-day cardiovascular mortality (OR: 1.03; 95% CI, 0.35-2.99), myocardial infarction (OR: 0.86; 95% CI, 0.14-5.28), acute kidney injury (OR: 0.89; 95% CI, 0.42-1.88), stroke (OR: 1.07; 95% CI, 0.38-2.97), or 1-year mortality (OR: 1.05; 95% CI, 0.71-1.56). The timing of percutaneous coronary intervention (same setting versus a priori) did not negatively influence outcomes.

Conclusions: Our analysis suggests that revascularization before transcatheter aortic valve implantation confers no clinical advantage with respect to several patient-important clinical outcomes and may be associated with an increased risk of major vascular complications and 30-day mortality. In the absence of definitive evidence, careful evaluation of patients on an individual basis is of paramount importance to identify patients who might benefit from elective revascularization.

Keywords: coronary artery disease; percutaneous coronary intervention; transcatheter aortic valve implantation.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aortic Valve Stenosis / complications
  • Aortic Valve Stenosis / mortality
  • Aortic Valve Stenosis / surgery*
  • Chi-Square Distribution
  • Coronary Artery Disease / complications
  • Coronary Artery Disease / mortality
  • Coronary Artery Disease / therapy*
  • Coronary Stenosis / complications
  • Coronary Stenosis / mortality
  • Coronary Stenosis / therapy*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Odds Ratio
  • Patient Selection
  • Percutaneous Coronary Intervention* / adverse effects
  • Percutaneous Coronary Intervention* / mortality
  • Postoperative Complications / etiology
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Time Factors
  • Transcatheter Aortic Valve Replacement* / adverse effects
  • Transcatheter Aortic Valve Replacement* / mortality
  • Treatment Outcome