Letter by Minten et al Regarding Article, "Management of Myocardial Revascularization in Patients With Stable Coronary Artery Disease Undergoing Transcatheter Aortic Valve Implantation"

HomeCirculation: Cardiovascular InterventionsVol. 16, No. 3Letter by Minten et al Regarding Article, “Management of Myocardial Revascularization in Patients With Stable Coronary Artery Disease Undergoing Transcatheter Aortic Valve Implantation” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Minten et al Regarding Article, “Management of Myocardial Revascularization in Patients With Stable Coronary Artery Disease Undergoing Transcatheter Aortic Valve Implantation” Lennert Minten, Johan Bennett and Christophe Dubois Lennert MintenLennert Minten https://orcid.org/0000-0001-5290-6320 Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Belgium. Department of Cardiovascular Medicine, University Hospitals Leuven, Belgium. Search for more papers by this author , Johan BennettJohan Bennett https://orcid.org/0000-0002-8301-4517 Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Belgium. Department of Cardiovascular Medicine, University Hospitals Leuven, Belgium. Search for more papers by this author and Christophe DuboisChristophe Dubois Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Belgium. Department of Cardiovascular Medicine, University Hospitals Leuven, Belgium. Search for more papers by this author Originally published1 Mar 2023https://doi.org/10.1161/CIRCINTERVENTIONS.123.012877Circulation: Cardiovascular Interventions. 2023;16Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 1, 2023: Ahead of Print Stable coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI): what are the real questions? We read with great interest the study by Costa et al1 about the effects of complete revascularization of stable CAD in patients undergoing TAVI. We would like to congratulate the authors for this nicely executed multicenter study. It entails an interesting field of research, and we acknowledge the challenges in conducting a multicenter study with a sizeable number of patients. By performing the elegant statistical matching, 2 groups of comparable baseline risk were created. Moreover, the study population is representative of our daily patient population. However, we have some remarks and observations. First, in our view, the 2 most important questions in this population are as follows: (1) should we perform percutaneous coronary intervention (PCI) of stable CAD in the peri-TAVI period? This study does not provide a clear answer to this question, since in the incomplete revascularization group, although the name might not suggest it, 56% of the patients did not receive revascularization and 44% received incomplete revascularization. Perhaps better, in our opinion, to divide the population into 3 groups: PCI with complete revascularization, PCI with incomplete revascularization, and stable CAD without revascularization. Such an analysis might come closer to answering the first question. (2) If we decide to perform PCI, should we aim for complete revascularization? Unfortunately, the current study also does not provide us with this answer. One might suspect the complete revascularization group to undergo more elaborate PCI, hence the more complete revascularization. However, unfortunately, the opposite is true. The incomplete revascularization group underwent more frequent left main/proximal left anterior descending artery PCI and also significantly more multivessel PCI. This would suggest that the difference between the 2 groups is based on the baseline complexity of CAD and not the strategy of PCI (which is the real question). This suspicion is confirmed by the fact that patients with incomplete revascularization did indeed have more frequent multivessel, 3-vessel, and calcific CAD. A potential solution to this problem could have been to include baseline complexity of CAD (eg, scored by the SYNTAX score [Synergy Between PCI With Taxus and Cardiac Surgery]2) as a variable included in the propensity score matching. Using baseline CAD complexity in the matching to create 3 groups of patients, as suggested above, would have provided us with interesting information for daily clinical practice.Second, using coronary physiology in this population is an interesting option and was used in 7.5% of the revascularizations. Using coronary physiology to guide revascularization in TAVI patients can be challenging since there are multiple complicated physiological changes at play.3 Recently, a small study has suggested that fractional flow reserve remains more stable when compared with resting full-cycle ratio after TAVI; however, more research is needed to confirm this.4,5 In our opinion, it might have been better not to include the patients who underwent physiology-guided PCI or to analyze them as a separate group. This in order not to mix different methods of PCI selection and to evaluate the merit of angiography-guided PCI (which is currently the most frequent strategy to select lesions).Article InformationSources of FundingDr Minten is supported by the Research Foundation Flanders grant 1194521 N.Disclosures None.FootnotesFor Sources of Funding and Disclosures, see page 144–145.References1. Costa G, Pilgrim T, Santos IJA, Backer OD, Kim W-K, Ribeiro HB, Saia F, Bunc M, Tchetche D, Garot P, et al. Management of myocardial revascularization in patients with stable coronary artery disease undergoing transcatheter aortic valve implantation.Circ Cardiovasc Interv. 2022; 15:e012417. doi: 10.1161/CIRCINTERVENTIONS.122.012417LinkGoogle Scholar2. Minten L, Wissels P, McCutcheon K, Bennett J, Adriaenssens T, Desmet W, Sinnaeve P, Verbrugghe P, Jacobs S, Guler I, et al. The effect of coronary lesion complexity and preprocedural revascularization on 5-year outcomes after TAVR.JACC Cardiovasc Interv. 2022; 15:1611–1620. doi: 10.1016/j.jcin.2022.06.019CrossrefMedlineGoogle Scholar3. Minten L, McCutcheon K, Bennett J, Dubois C. Coronary physiology to guide treatment of coronary artery disease in a patient with severe aortic valve stenosis: friend or foe? A case report.Eur Heart J Case Rep. 2022; 6:ytac333. doi: 10.1093/ehjcr/ytac333CrossrefMedlineGoogle Scholar4. Sabbah M, Joshi FR, Minkkinen M, Holmvang L, Tilsted HH, Pedersen F, Ahtarovski K, Sørensen R, Olsen NT, Søndergaard L, et al. Long-term changes in invasive physiological pressure indices of stenosis severity following transcatheter aortic valve implantation.Circ Cardiovasc Interv. 2022; 15:e011331. doi: 10.1161/CIRCINTERVENTIONS.121.011331LinkGoogle Scholar5. Minten L, McCutcheon K, Jentjens S, Vanhaverbeke M, Segers VFM, Bennett J, Dubois C. The coronary and microcirculatory measurements in patients with aortic valve stenosis study: rationale and design.Am J Physiol Heart Circ Physiol. 2021; 321:H1106–H1116. doi: 10.1152/ajpheart.00541.2021CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByCosta G, Tamburino C and Barbanti M (2023) Response by Costa et al to Letter Regarding Article, “Management of Myocardial Revascularization in Patients With Stable Coronary Artery Disease Undergoing Transcatheter Aortic Valve Implantation”, Circulation: Cardiovascular Interventions, 16:3, (e012895), Online publication date: 1-Mar-2023. March 2023Vol 16, Issue 3 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.123.012877PMID: 36856046 Originally publishedMarch 1, 2023 PDF download Advertisement SubjectsAortic Valve Replacement/Transcatheter Aortic Valve ImplantationCatheter-Based Coronary and Valvular InterventionsClinical StudiesCoronary Artery DiseaseCoronary CirculationMortality/SurvivalPercutaneous Coronary InterventionRevascularizationValvular Heart Disease