Incidence, clinical characteristics, and impact of acute coronary syndrome following transcatheter aortic valve replacement
Selected in JACC: Cardiovascular Interventions by S. Brugaletta
References
Authors
Vilalta V, Asmarats L, Ferreira-Neto AN, Maes F, de Freitas Campos Guimarães L, Couture T, Paradis JM, Mohammadi S, Dumont E, Kalavrouziotis D, Delarochellière R, Rodés-Cabau J
Reference
JACC Cardiovasc Interv. 2018 Dec 24;11(24):2523-2533
Published
December 2018
Link
Read the abstractReviewer
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Why this study – the rationale/objective?
About one-half of the patients undergoing transcatheter aortic valve replacement (TAVI) have concurrent coronary artery disease (CAD). However, the occurrence and clinical impact of coronary events following TAVR remain largely unknown. The authors sought to assess the incidence, predictors, management, and prognosis of acute coronary syndrome (ACS) following TAVR.
How was it executed – the methodology?
Consecutive patients undergoing TAVI in authors' Institution between May 2007 and November 2017 were included. Patients were followed at 1, 6, and 12 months, and yearly thereafter. ACS was diagnosed and classified according to the Third Universal Definition of Myocardial Infarction.
What is the main result?
A total of 779 patients were included, 68% of which had a history of CAD. At a median follow-up of 25 (interquartile range: 10 to 44) months, 78 patients (10%) presented at least 1 episode of ACS, with one-half of the events occurring within the year following TAVI.
Clinical presentation was type 2 non-ST-segment elevation myocardial infarction (35.9%), unstable angina (34.6%), type 1 non–ST-segment elevation myocardial infarction (28.2%), and ST-segment elevation myocardial infarction (1.3%).
Male sex (hazard ratio [HR]: 2.19; 95% confidence interval [CI]: 1.36 to 3.54; p=0.001), prior CAD (HR: 2.78; 95% CI: 1.50 to 5.18; p=0.001), and non-transfemoral approach (HR: 1.71; 95% CI: 1.04 to 2.75; p=0.035) were independently associated with ACS. Coronary angiography was performed in 53 (67.9%) patients with ACS, and 30 of them (56.6%) underwent percutaneous coronary intervention.
In-hospital death rate at the time of the ACS episode was 3.8%. At a median follow-up of 21 (interquartile range: 8 to 34) months post-ACS, all-cause and cardiovascular death rates were 37.3% and 25.3%, respectively.
Critical reading and the relevance for clinical practice
Treatment of an ACS in TAVI patients after their discharge is a topic of interest, but there are unfortunately few data available.
In this interesting article, the authors collected all the data available in their Institution, finding that approximately one-tenth of patients undergoing TAVI were readmitted for an ACS after a median follow-up of 25 months.
Male sex, prior CAD, and inadequate ilio-femoral access were independent predictors of ACS. ACS was associated with high midterm mortality.
These data can be used for risk stratification and tailor management of patients presenting with ACS post-TAVI in order to improve mid to long-term outcomes, enhancing for example preventive measures.
Thinking about the increasing use of TAVI and reducing age of TAVI patients in the coming years, we may think about an increase in the need for ACS treatment in such patients. It is of note not only to know which are the predictive ACS factors but also to understand the technical challenges to treat such patients.
Has any of you experienced with ACS in TAVI patients and would like to share with the community?
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