Some Guidance for Managing Patients With AS and CAD: Review

In patients with both aortic stenosis (AS) and coronary artery disease, decisions about whether to revascularize and how can be complex—a new review paper aims to make this process more consistent.

“On average, approximately half of all patients with aortic stenosis that undergo TAVI will have coronary artery disease,” co-author Thomas Pilgrim, MD (Bern University Hospital, Switzerland), told TCTMD. “We don't really have a perfect strategy [for] how to deal with these patients.”

The landmark TAVI trials, he noted, excluded patients with CAD. With so many permutations of treatment options—CABG and surgical AVR, PCI before TAVI, concomitant PCI and TAVI, PCI after TAVI, and hybrid procedures to name a few—the authors wanted to evaluate available evidence in the space to guide heart team discussions and clinical decision-making.

Gilbert Tang, MD (Mount Sinai Health, New York, NY), who wasn’t part of the review, said the heart team for valvular disease has become “pretty robust” but acknowledged there is less thought around concomitant CAD. “Aortic stenosis is pretty straightforward now,” he said. “There's guidelines and criteria, but once you add the complexity of CAD, it's a bit more nuanced in terms of what to do.”

Further, he argued, “right now with TAVR being the default for almost all patients, surgery is almost coming as an afterthought.” The AS takes precedence and patients are often referred for TAVI unless they are anatomically unsuitable, but their coronary disease isn’t given as much consideration as it should be, Tang added.

The document was published online recently in Circulation.

New Studies in 2024

Current guidelines aren’t particularly clear on how these patients should be treated, but generally recommend two separate procedures, with concomitant procedures only recommended for those with very high degrees of coronary artery stenosis. For those with complex CAD, both SAVR and CABG are usually recommended at the same time.

Most of the available evidence comes from smaller-scale studies, with NOTION-3 making the most recent splash in this space. That trial showed a strategy of PCI before TAVI, compared with medical therapy before TAVI, lowered the relative risk of all-cause mortality, MI, or urgent revascularization over 2 years by 29% in patients with stable CAD and severe AS. Because the main benefit in NOTION-3 was derived from a reduction in the need for coronary revascularization, however, some argued that the trial was not a slam dunk for PCI before TAVI in all patients.

Another observational study published this year showed that in patients undergoing TAVI for severe AS, residual obstructive CAD can safely be watched without stenting, even in the case of significant left main and triple-vessel disease.

Also, the TCW trial, presented at EuroPCR 2024 and published in the Lancet this month, showed a fivefold higher risk of major adverse events in patients treated with combined SAVR and CABG compared with a combined TAVI and PCI. That trial was stopped early and garnered a mix of shock and suspicion when it was released.

The ongoing COMPLETE TAVR trial of 4,000 patients comparing FFR-guided PCI with complete revascularization to medical therapy after TAVI will likely give “a more definitive answer” to how best to proceed, Pilgrim said.

Still, another big question remains as to how to best diagnose CAD in patients with AS because coronary hemodynamics reflects the combined effect of both diseases “and then noninvasive testing is usually discouraged because patients have increased risk of arrhythmias,” he explained. Interpreting FFR in these patients can also “be very challenging, . . . so it's not so straightforward to really apply the diagnostic tools for coronary artery disease in this population with aortic stenosis.”

Heart Team Considerations

For Rishi Puri, MD, PhD (Cleveland Clinic, OH), this review paper is timely. The NOTION-3 trial represented “somewhat of a seminal moment” in the field of CAD and AS, particularly for those slated for TAVI. “There's a bit of a buzz going around now,” he said. “We have some evidence finally, [but] how do we translate the trial results to the patients that are in front of us day to day. There are many views to that because the phenotype of the CAD/AS patient is so variable and nuanced.”

While he’s glad to see more research come out in this space—and agrees that COMPLETE TAVR will have a profound impact as well as the ongoing FAITAVI trial—Puri said treating these patients is “always, in my humble opinion, going to be a combination of art and science.”

More trials will “fill parts of the big jigsaw puzzle, but the jigsaw puzzle is never going to be solved completely for every type of AS/CAD patient” given the complexity of the patient’s disease and various comorbidities as well as evolving iterations in valve design and future options, he specified.

“That's why we have robust discussions, and we shouldn't be talking about things that we don't individually do. I'm an interventional cardiologist, I don't do open heart surgery, but I work with an amazing team of surgeons,” Puri said. “I tell the patient what we can deliver with a catheter-based approach, present the evidence, tell them where we think they fit, and let them have an independent discussion with the surgeons. Then, let's all come together and see what the patient wants and what they're willing to take on based on their specific goals of care.”

This is undoubtedly more likely to happen in large academic centers with experienced TAVI operators as well as prolific surgeons, he acknowledged.

Moving forward, Tang suggested that it’s time for the heart team to also focus on CAD burden risks of revascularization.

The biggest challenge here resides in the core of the heart team and its ability to look at the full picture of a patient’s needs, he said. “Most of the coronary disease [patients] now are managed by interventional cardiologists. They might not necessarily consult a surgeon,” according to Tang. For many, incorporating surgeons into this workflow earlier and consistently will likely pay off,” he added.

Pilgrim, too, stressed the importance of the heart team for this patient population.

“Most patients are more complex than in randomized trials because they don't have one isolated disease, but they have a combination of medical problems. . . . We need to take into account this entire complexity of comorbidity,” he said.