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PCI for ACS After TAVR Mostly Succeeds, Valve Choice May Matter

Coronary angiography and percutaneous coronary interventions (PCI) for acute coronary syndromes can be performed successfully after transcatheter aortic valve replacement in most cases, according to data drawn from an international registry that has collected more than 400 such cases.

Overall, reaccess coronary angiography was successful in about 99% of cases with type of prosthesis identified as the most important variable in predicting success, according to a multicenter investigating team led by Won-Keun Kim, MD, director of structural heart disease, Kerckhoff Heart Center, Bad Nauheim, Germany.

By type of prosthesis, Kim was referring to long versus short stent-frame prostheses (SFP). In the case of angiography of the right coronary artery, for example, success was achieved in 99.6% of those with a short SFP and 95.9% of those with a long SFP (= .005).

The study was published online in JACC: Cardiovascular Interventions.

Based on these and previous data, “prosthetic choice will be the main decisive factor that affects coronary reaccess, and this decision is in the hands of the TAVR operator,” said  Kim in an interview.

This does not preclude use of a long SFP in TAVR. For patients with increased likelihood of eventually requiring a coronary intervention after TAVR, such as those undergoing the procedure at a relatively young age, a short device appears to be preferable, but  Kim emphasized that it is not the only consideration.

When performing TAVR, “the highest priority is to accomplish a safe procedure with a good immediate outcome,” he said, pointing out that angiographic reaccess and PCI are successfully achieved in most patients whether fitted with a short or long SFP.

“If for any reason I assume that the immediate outcome [after TAVR] might be better using a long SFP, I would not hesitate to use a long SFP,” said  Kim, giving such examples as a need for resheathing or precise positioning.

Coronary Reaccess Has Low Relative Priority

“Coronary reaccess is an important issue and there is an increasing awareness of this, but it has a lower priority” than optimizing TAVR success,”  Kim explained.

The analysis of coronary angiographic reaccess was based on 449 TAVR patients from 25 sites who required reaccess angiography. The indication in most cases was an acute coronary syndrome, mostly non–ST-elevation myocardial infarction (STEMI, 79%). Of the remaining patients, about half had STEMIs and half had other acute cardiovascular situations. The median time interval from TAVR to need for coronary angiography was 311 days.

In all but 2.7%, diagnostic catheterization was performed initially. It was successful in 98.3% of the procedures in the right coronary artery, 99.3% of the left coronary artery, and 97.3% overall.

Of the 60% who underwent PCI, 9% were considered unsuccessful. The reasons included lack of reflow in eight cases and coronary access issues in six cases. A variety of other issues accounted for the remaining seven cases.

Technical success was achieved in 91.4% of native arteries. In the six cases in which engagement of the culprit vessel with a guiding catheter failed, three were converted to urgent coronary bypass grafting and three died in the hospital. Neither selective versus unselective guiding-catheter engagement nor long versus short SFP related to PCI success, but PCI was performed less commonly in the native coronary arteries of TAVR patients with a long rather than short SFP (49% vs. 57%).

The 30-day all-cause mortality in this series was 12.2%. The independent predictors were a history of diabetes and the occurrence of cardiogenic shock. In the PCI subgroup, these factors plus PCI success predicted 30-day mortality.

Strategies to Improve Reaccess Not Resolved

When performing TAVR, other factors that might influence subsequent PCI success includes commissural alignment and positioning, according to  Kim. But he cautioned that there are a number of potential controversies when weighing how to improve chances of post-TAVR angiographic reaccess without compromising the success of valve replacement.

“Lower positioning facilitates coronary access, but unfortunately will increase rates of conduction disturbances,” he noted.

Overall, one of the main messages from this analysis is that “the fear of impaired coronary access [after TAVR] may well be disproportionate to the reality,” according to Neal S. Kleiman, MD, an interventional cardiologist at Houston Methodist DeBakey Heart and Vascular Center. Kleiman wrote an editorial on the registry findings in the same issue of JACC: Cardiovascular Interventions).

Yet, he agreed that the issue of angiographic reaccess after TAVR cannot be ignored. Although reaccess after TAVR has so far been “surprisingly rare,”  Kleiman expects cases to increase as more younger patients undergo TAVR. He suggested that interventionalists will need consider this issue when performing TAVR, a point he reemphasized in an interview.

“It is still a concern when recommending TAVR to a patient and still poses challenges to device manufacturers,” said  Kleiman, suggesting that “a new set of skills” will be required to perform TAVR that will optimize subsequent angiographic access and PCI.

Kim agreed. Ultimately, other challenges, such as PCI performed after TAVR-in-TAVR placement, are likely to further complicate this issue, but he, too, is looking to new devices to minimize the problems.

“It would be desirable to modify the design, especially of long SFPs, to improve access for PCI, and there are ongoing efforts of the manufacturers to achieve this,”  Kim said.

Kim reported financial relationships with Abbott, Boston Scientific, Edwards Lifesciences, Medtronic, and Meril Lifesciences. Kleiman reported financial relationships with Abbott, Boston Scientific, Edwards Lifesciences, and Medtronic.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.


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