The management of coronary artery disease (CAD) patients undergoing transcatheter aortic valve replacement (TAVR) should be individualized based on the patient’s overall clinical condition and anatomy, according to a council perspective from ACC’s Interventional Section Leadership Council, published Dec. 5 in JACC: Cardiovascular Interventions. 

Stephen Ramee, MD, FACC, et al., explain that that there is no evidence proving the safety of TAVR without prior percutaneous coronary intervention (PCI) of severe coronary lesions. Since the guidelines for PCI were completed before the role of PCI in pre-TAVR patients became a clinical issue, they state that “it would be wrong to extrapolate current ACC/American Heart Association recommendations against invasive procedures in asymptomatic patients to the TAVR population when evaluating the quality of care by cardiologists or hospitals.” The Council believes it is necessary to update the recommendations since the current practice is to follow the protocol requiring all major coronary arteries with significant stenosis to undergo PCI before TAVR despite there being no current professional society recommendations.

The statement cites a number of studies on PCI and TAVR that have resulted in different conclusions depending on patient symptoms, risk level and other factors. They note that specific clinical and anatomic considerations must be made in patient selection; i.e., whether the patient is symptomatic with combined CAD and aortic stenosis, has untreated significant stenoses, is symptomatic with angina or heart failure, or other concerns. “The decision to perform PCI should take into consideration left ventricular ejection fraction, lesion location and severity, morphologic complexity and technical feasibility,” they explain.

The Council ultimately recommends that PCI should be considered in all patients with significant proximal coronary stenosis in major coronary arteries before TAVR. They do not advocate performing PCI on a chronic total occlusion in the absence of ischemia or symptoms prior to TAVR.

Moving forward, the Council proposes the use of a clinical algorithm to assess the need for pre-TAVR PCI and make sure that risk does not outweigh the potential benefits. “In addition to assessment of procedural risk, consideration should be given to whether CAD may be contributing to the patient’s symptoms,” the authors note. “In those situations where it may be the primary cause of symptoms, PCI may be performed, and the need for TAVR re-evaluated.” 

Keywords: Algorithms, American Heart Association, Angina Pectoris, Aortic Valve Stenosis, Boehmeria, Constriction, Pathologic, Coronary Angiography, Coronary Artery Disease, Coronary Stenosis, Heart Failure, Leadership, Patient Selection, Percutaneous Coronary Intervention, Stroke Volume, Transcatheter Aortic Valve Replacement, United States, Angiography, Cardiology Magazine, ACC Publications