PCI Post-TAVI Shows Better 2-Year Outcomes Than Concurrent or Pre-TAVI Procedures
At 2 years, percutaneous coronary intervention (PCI) performed after transcatheter aortic valve implantation (TAVI) showed significantly lower rates of all-cause death and a composite endpoint compared with other PCI timings relative to TAVI, a new analysis shows.
Michael Joner, MD, of the German Heart Center in Munich, reported these findings Tuesday during a Late-Breaking Trial presentation at Cardiovascular Research Technologies (CRT) 2023 in Washington, D.C.
Because of similar risk factors, aortic valve stenosis (AVS) and coronary artery disease (CAD) often occur together. Clinicians continue to debate the assessment of CAD severity in AVS cases, revascularization methods and timing for both procedures.
Guidelines currently recommend PCI based on angiographic assessments in patients scheduled for TAVI who have coronary artery lesions with >70% stenosis in proximal segments (> 50% if left main disease). It has yet to be determined what time is best for TAVI patients to undergo PCI.
The investigators conducted a subanalysis of the REVASC-TAVI Registry, which was a multicenter, international study with 30 participating centers spread across Europe, Japan, and North and South America. The registry enrolled patients who underwent TAVI for symptomatic, severe aortic stenosis or staged/concomitant PCI for CCS from January 2015 through September 2021.
Patients (n = 1617) were assigned to three groups for this analysis: PCI before TAVI (staged, elective PCI performed in a different session prior to TAVI [n = 1052]), concomitant PCI (staged, elective PCI performed in a separate session after TAVI [n = 394]) and PCI after TAVI (before or after implantation, elective PCI performed within the same session as TAVI [n = 152]). The primary outcome was all-cause mortality, and the co-primary outcome was a composite of all-cause death, stroke, myocardial infarction and re-hospitalization for congestive heart failure, with both outcomes assessed at 2-year follow-up.
The 2-year all-cause death rate was significantly lower in the PCI-post-TAVI group (6.8%) than in the concomitant PCI-TAVI group (20.1%) or the PCI-pre-TAVI group (20.6%). The hazard ratio (HR) for PCI before vs. after TAVI was 3.21 (95% confidence interval [CI]: 1.47, 7.00; p=0.003), and the HR FOR concomitant PCI vs. PCI after TAVI was 3.23 (95% CI: 1.42, 7.39; p=0.005).
The 2-year composite rate of all-cause death, stroke, myocardial infarction or heart failure rehospitalization followed a similar pattern. The rate was significantly lower in the PCI-post-TAVI group (17.4%) than in either the concomitant PCI-TAVI group (30.0%) or the PCI-pre-TAVI group (30.4%). The HR for PCI before vs. after TAVI was 2.0 (95% CI: 1.16, 3.45; p=0.013), and the HR for concomitant PCI vs. PCI after TAVI was 2.03 (95% CI: 1.09, 3.79; p=0.026).
Thus far, this is the largest known study on PCI timing strategies in patients undergoing TAVI. PCI was performed prior to TAVI in two-thirds of the patients in this study, Joner said.
However, Joner noted some limitations, including those inherent to a retrospective, non-randomized study design. The timing decision was at the treating physician’s description, which means confounding factors for differences in outcomes cannot be ruled out. There is selection bias, as patients treated with staged PCI before TAVI who died before undergoing TAVI or vice versa were not accounted for. And the results of this analysis are limited to patients with chronic coronary syndrome, meaning they cannot be generalized to patients with acute coronary syndromes.
Image Credit: Jason Wermers/CRTonline.org
