Length of Time Between Staged PCI, TAVR Minimally Affects Short-term Outcomes

Timing of staged PCI before TAVR does not affect long-term clinical outcomes or survival, according to a study published online March 24, 2015, ahead of print in the American Journal of Cardiology. However, those who undergo PCI within 30 days prior to TAVR are more apt to experience minor vascular injury and minor bleeding.

Researchers led by Victoria Delgado, MD, PhD, of Leiden University Medical Center (Leiden, the Netherlands), looked at 96 patients (average age 81 years; 57% men) with CAD and severe aortic stenosis who received staged PCI less than or at least 30 days—but within 1 year—before TAVR. Overall mean logistic EuroSCORE was 23.2 ± 13.9, and baseline characteristics were comparable between the groups. Patients treated within 30 days of TAVR, however, had lower levels of baseline hemoglobin and were more likely to present with A-fib.

Procedural characteristics were similar between the study arms, but patients who underwent TAVR within 30 days of PCI were more often implanted with more stents than those who had PCI earlier (mean of 2.3 vs 1.5; P = .011). There was no difference between groups regarding contrast volume or use of DES and BMS.

No Impact on 2-Year Survival

Utilizing Valve Academic Research Consortium (VARC)-2 criteria, patients treated within 30 days of PCI more often had vascular injury at 30 days after TAVR than those treated earlier, but this disparity was driven by a higher frequency of minor as opposed to major events. These patients were also more likely to experience minor bleeding, but other outcomes did not differ (table 1).

Importantly, 2-year survival rates were comparable between those who had PCI within compared with more than 30 days before TAVR (75% vs 77%; P = .363).

A Paucity of Data on Timing

“Significant CAD is relatively frequent in patients with severe aortic stenosis undergoing [TAVR],” Dr. Delgado and colleagues write, adding, “Revascularization prior to [TAVR] may be protective, reducing the ischemia burden during valve ballooning and prosthesis deployment.”

They say the study findings “underscore the importance of several factors that need to be weighted when considering PCI prior to [TAVR].” These include:

• Clinical characteristics and associated comorbidities of patients
• Severity of CAD
• Odds of complete or incomplete revascularization

But data are limited regarding the timing of PCI before TAVR, the authors note. “Staged PCI prior to [TAVR] and combined PCI and [TAVR] are the most frequent strategies used…. However, patients undergoing staged PCI prior to [TAVR] are loaded with dual antiplatelet treatment, which may increase the risk of bleeding complications.”

In contrast, combined PCI and TAVR “may be preferred in some patients since both procedures share the same arterial access, reducing the risks of vascular injury and bleedings,” they suggest, noting, however, that this strategy has been little studied and is more likely to result in greater use of contrast volume.

“The results of the ongoing ACTIVATION trial will shed light [on] the optimal revascularization strategy prior to [TAVR], whereas the ongoing ARTE trial will show the most appropriate antiplatelet treatment (aspirin vs aspirin and clopidogrel) in patients without indications for anticoagulation,” the authors say. They add that future studies will also need to determine if a radial approach for PCI will help to reduce vascular complications after TAVR more than a femoral approach.

Source:
van Rosendael PJ, van der Kley F, Kamperidis V, et al. Timing of staged percutaneous coronary intervention prior to transcatheter aortic valve implantation. Am J Cardiol. 2015;Epub ahead of print. 

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