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TAVR plus left main PCI shows promise in severe aortic stenosis
The proximity of the left main coronary artery ostium and the aortic annulus has presented concern regarding the role of transcatheter aortic valve replacement plus left main PCI, but consecutive use of the two procedures appears to be safe and technically feasible, yielding outcomes comparable to those achieved with transcatheter aortic valve replacement alone, according to results from the TAVR-LM registry.
In the retrospective study, Tarun Chakravarty, MD, of Cedars-Sinai Heart Institute, and colleagues collected data on 204 consecutive patients undergoing TAVR plus left main PCI at 11 medical centers in North America, Europe and Canada between 2007 and 2014. Case-control matching was used to generate 128 matched patient pairs from 167 patients with pre-existing stents and 1,118 control patients undergoing TAVR without left main PCI. Of the patients undergoing TAVR plus left main PCI, three groups were established: those undergoing planned left main PCI (n = 176); those undergoing unplanned left main PCI (n = 19); and those undergoing post-TAVR PCI (n = 9). The researchers evaluated clinical, echocardiographic, CT and angiographic data in all groups and compared the outcomes of those undergoing TAVR plus left main PCI vs. TAVR alone.
The researchers found a comparable mortality rate between the TAVR plus PCI patients vs. the matched controls at 30 days (3.1% vs. 2.3%; P = .67) and at 1 year (9.4% vs. 10.2%; P = .83). Among the patients who underwent TAVR plus left main PCI, no difference was seen in 1-year mortality between patients with unprotected left main disease vs. protected left main disease (7.8% vs. 8.1%; P = .88).
In a comparison of mortality based on the timing of left main PCI, researchers found no difference between those undergoing left main PCI within 3 months vs. those who underwent left main PCI more than 3 months before TAVR (7.4% vs. 8.6%; P = .61). Moreover, compared with performing left main PCI more than 3 months before TAVR, timing left main PCI within 3 months before TAVR was not associated with increased risk for acute kidney injury (6.3% within 3 months vs. 5.2% more than 3 months; P = .76); major vascular complications (13.7% vs. 12.3%; P = .79) or life-threatening bleeding (13.7% vs. 14.8%; P = .83).
An analysis based on stent location revealed no significant difference between those with ostial vs. non-ostial left main stents (10.3% vs. 15.6%; P = .2).
Compared with those who underwent planned left main PCI, patients who underwent unplanned left main PCI due to TAVR-associated coronary complications had increased mortality at 30 days (15.8% unplanned vs. 3.4% planned; P = .013) and at 1 year (21.1% vs. 8%; P = .071).
According to the researchers, randomized trials are needed to assess the outcomes of patients with coexisting left main disease and aortic stenosis undergoing surgical vs. percutaneous procedures.
“Despite the anatomic proximity of the aortic valve annulus to the ostium of the [left main], patients with symptomatic, severe [aortic stenosis], and [left main] disease who are poor candidates for an open surgical approach can be successfully managed with TAVR, even in the presence of ostial lesions, and TAVR can be performed before or after stenting of the [left main],” the researchers wrote. – by Jennifer Byrne
Disclosure: Chakravarty reports no relevant financial disclosures. Please see the full study for a list of all other researchers’ relevant financial disclosures.