ACC Document Addresses Rationale for Performing PCI Before TAVR

December 12, 2016—The rationale for performing coronary angiography and stenting before transcatheter aortic valve replacement (TAVR) was analyzed by the Aortic Stenosis Appropriate-Use-Criteria Writing Group from the Interventional Section Leadership Council of the American College of Cardiology (ACC). Stephen Ramee, MD, et al published the document in the Journal of the American College of Cardiology (JACC): Cardiovascular Interventions (2016;9:2371–2375).

As summarized in JACC: Cardiovascular Interventions, TAVR is an effective, nonsurgical treatment option for patients with severe aortic stenosis but the optimal treatment strategy for treating concomitant coronary artery disease (CAD) has not been tested prospectively in a randomized clinical trial. Nevertheless, it is standard practice in the United States to perform coronary angiography and percutaneous coronary intervention (PCI) for significant CAD at least 1 month before TAVR. All existing clinical trials were designed using this strategy. Therefore, it is wrong to extrapolate current ACC/American Heart Association Appropriate Use Criteria against invasive procedures in asymptomatic patients to the TAVR population when evaluating the quality of care by cardiologists or hospitals, advised the authors.

The statement recommends that PCI should be considered in all patients with significant proximal coronary stenosis in major coronary arteries before TAVR, even though the indication is not covered in current guidelines.

The authors note that severe aortic stenosis has previously been considered a contraindication to PCI. The risk of PCI in this setting was considered to be high, because of physiologic considerations and concern for complications; however, recent studies have evaluated PCI outcomes in AS and have shown that the results can be favorable if patients are carefully selected. The document briefly reviews those studies. Additionally, the document outlines specific clinical and anatomic considerations in patient selection.

The document's recommendations include:

• Management of CAD in patients undergoing TAVR should be individualized based on the patient’s overall clinical condition and anatomy. These patients have contraindications to stress testing. 
• Based on previous clinical trial protocols and the CMS mandate, all patients with aortic stenosis undergoing evaluation for TAVR require coronary angiography. 
• PCI should be considered for major coronary arteries with significant proximal stenosis before TAVR, even though the indication is not covered in current guidelines.
• A proposed clinical algorithm (illustrated in the document) should be used to assess the need for PCI before TAVR. In patients with > 70% stenosis in a proximal epicardial vessel or the left main, the decision to perform PCI should be made before or at the time of TAVR as long as the risk of the procedure does not outweigh the potential benefits. 
• In the setting where the coronary stenoses are located in branch or mid/distal epicardial vessels, with small areas of ischemia, the decision of whether to perform PCI may be postponed until after TAVR, unless access to the coronary artery will be limited by the transcatheter valve. 
• In addition to assessment of procedural risk, consideration should be given to whether CAD may be contributing to the patient’s symptoms. In those situations where it may be the primary cause of symptoms, PCI may be performed, and the need for TAVR reevaluated. 

The authors do not advocate performing PCI on a chronic total occlusion in the absence of ischemia or symptoms before TAVR. As TAVR becomes more widely practiced in patients with a better long-term prognosis, these considerations will be of greater importance, noted the authors in JACC: Cardiovascular Interventions.