Impact of Extent of Coronary Artery Disease in Transcatheter Aortic Valve Replacement: A PRO-TAVI Substudy.

BACKGROUND

Coronary artery disease is present in one-half of patients undergoing transcatheter aortic valve replacement (TAVR). The recent randomized controlled PRO-TAVI (Percutaneous Coronary Intervention Before Transcatheter Aortic Valve Implantation) trial indicated that deferral of percutaneous coronary intervention (PCI) is safe in patients with concomitant coronary artery disease at 1-year follow-up. The SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score quantifies the extent of coronary artery disease, which may guide individualized revascularization strategies.

OBJECTIVES

The aim of this study was to evaluate the association between SYNTAX score (SS) and clinical outcomes in patients undergoing TAVR.

METHODS

This study was a substudy of the PRO-TAVI trial, including 466 patients with significant coronary artery disease undergoing TAVR randomized to deferral of PCI or PCI before TAVR. SS was calculated from preprocedural coronary angiograms, and patients were stratified by SS quartiles. The primary outcome was a composite of all-cause mortality, myocardial infarction, stroke, and major bleeding at 1 year. An ischemic composite outcome of all-cause mortality, myocardial infarction, and stroke was also assessed.

RESULTS

The primary composite outcome did not differ across SS categories between the deferral and PCI groups at 1-year follow-up, which was completed by all but 1 patient. In patients with SS >17, the ischemic composite outcome occurred more often in the deferral group (30.9% vs 14.8%; adjusted HR: 2.43; 95% CI: 1.04-5.64; P = 0.04), driven primarily by all-cause mortality and stroke. Bleeding events were less frequent in the deferral group across all SS subgroups.

CONCLUSIONS

In patients with concomitant coronary artery disease undergoing TAVR, deferral of PCI reduced bleeding risk and appeared safe across all SS categories. Deferral of PCI in patients with more complex coronary artery disease (SS >17) was associated with higher risk for the ischemic composite outcome. These post hoc findings require confirmation in randomized trials. (Percutaneous Coronary Intervention Before Transcatheter Aortic Valve Implantation [PRO-TAVI]; NCT05078619).