TY - JOUR
T1 - Determining the Predominant Lesion in Patients With Severe Aortic Stenosis and Coronary Stenoses
T2 - A Multicenter Study Using Intracoronary Pressure and Flow
AU - Ahmad, Yousif
AU - Vendrik, Jeroen
AU - Eftekhari, Ashkan
AU - Howard, James P
AU - Cook, Christopher
AU - Rajkumar, Christopher
AU - Malik, Iqbal
AU - Mikhail, Ghada
AU - Ruparelia, Neil
AU - Hadjiloizou, Nearchos
AU - Nijjer, Sukhjinder
AU - Al-Lamee, Rasha
AU - Petraco, Ricardo
AU - Warisawa, Takayuki
AU - Wijntjens, Gilbert W M
AU - Koch, Karel T
AU - van de Hoef, Tim
AU - de Waard, Guus
AU - Echavarria-Pinto, Mauro
AU - Frame, Angela
AU - Sutaria, Nilesh
AU - Kanaganayagam, Gajen
AU - Ariff, Ben
AU - Anderson, Jon
AU - Chukwuemeka, Andrew
AU - Fertleman, Michael
AU - Koul, Sasha
AU - Iglesias, Juan F
AU - Francis, Darrel
AU - Mayet, Jamil
AU - Serruys, Patrick
AU - Davies, Justin
AU - Escaned, Javier
AU - van Royen, Niels
AU - Götberg, Matthias
AU - Juhl Terkelsen, Christian
AU - Høj Christiansen, Evald
AU - Piek, Jan J
AU - Baan, Jan
AU - Sen, Sayan
N1 - Publisher Copyright:
© 2019 American Heart Association, Inc.
PY - 2019/12/1
Y1 - 2019/12/1
N2 - BACKGROUND: Patients with severe aortic stenosis (AS) often have coronary artery disease. Both the aortic valve and the coronary disease influence the blood flow to the myocardium and its ability to respond to stress; leading to exertional symptoms. In this study, we aim to quantify the effect of severe AS on the coronary microcirculation and determine if this is influenced by any concomitant coronary disease. We then compare this to the effect of coronary stenoses on the coronary microcirculation.METHODS: Group 1: 55 patients with severe AS and intermediate coronary stenoses treated with transcatheter aortic valve implantation (TAVI) were included. Group 2: 85 patients with intermediate coronary stenoses and no AS treated with percutaneous coronary intervention were included. Coronary pressure and flow were measured at rest and during hyperemia in both groups, before and after TAVI (group 1) and before and after percutaneous coronary intervention (group 2).RESULTS: Microvascular resistance over the wave-free period of diastole increased significantly post-TAVI (pre-TAVI, 2.71±1.4 mm Hg·cm·s-1 versus post-TAVI 3.04±1.6 mm Hg·cm·s-1 [P=0.03]). Microvascular reserve over the wave-free period of diastole significantly improved post-TAVI (pre-TAVI 1.88±1.0 versus post-TAVI 2.09±0.8 [P=0.003]); this was independent of the severity of the underlying coronary stenosis. The change in microvascular resistance post-TAVI was equivalent to that produced by stenting a coronary lesion with an instantaneous wave-free ratio of ≤0.74.CONCLUSIONS: TAVI improves microcirculatory function regardless of the severity of underlying coronary disease. TAVI for severe AS produces a coronary hemodynamic improvement equivalent to the hemodynamic benefit of stenting coronary stenoses with instantaneous wave-free ratio values <0.74. Future trials of physiology-guided revascularization in severe AS may consider using this value to guide treatment of concomitant coronary artery disease.
AB - BACKGROUND: Patients with severe aortic stenosis (AS) often have coronary artery disease. Both the aortic valve and the coronary disease influence the blood flow to the myocardium and its ability to respond to stress; leading to exertional symptoms. In this study, we aim to quantify the effect of severe AS on the coronary microcirculation and determine if this is influenced by any concomitant coronary disease. We then compare this to the effect of coronary stenoses on the coronary microcirculation.METHODS: Group 1: 55 patients with severe AS and intermediate coronary stenoses treated with transcatheter aortic valve implantation (TAVI) were included. Group 2: 85 patients with intermediate coronary stenoses and no AS treated with percutaneous coronary intervention were included. Coronary pressure and flow were measured at rest and during hyperemia in both groups, before and after TAVI (group 1) and before and after percutaneous coronary intervention (group 2).RESULTS: Microvascular resistance over the wave-free period of diastole increased significantly post-TAVI (pre-TAVI, 2.71±1.4 mm Hg·cm·s-1 versus post-TAVI 3.04±1.6 mm Hg·cm·s-1 [P=0.03]). Microvascular reserve over the wave-free period of diastole significantly improved post-TAVI (pre-TAVI 1.88±1.0 versus post-TAVI 2.09±0.8 [P=0.003]); this was independent of the severity of the underlying coronary stenosis. The change in microvascular resistance post-TAVI was equivalent to that produced by stenting a coronary lesion with an instantaneous wave-free ratio of ≤0.74.CONCLUSIONS: TAVI improves microcirculatory function regardless of the severity of underlying coronary disease. TAVI for severe AS produces a coronary hemodynamic improvement equivalent to the hemodynamic benefit of stenting coronary stenoses with instantaneous wave-free ratio values <0.74. Future trials of physiology-guided revascularization in severe AS may consider using this value to guide treatment of concomitant coronary artery disease.
KW - Aged
KW - Aged, 80 and over
KW - Aortic Valve Stenosis/diagnosis
KW - Aortic Valve/physiopathology
KW - Blood Flow Velocity
KW - Cardiac Catheterization
KW - Coronary Artery Disease/diagnosis
KW - Coronary Circulation
KW - Coronary Stenosis/diagnosis
KW - Coronary Vessels/physiopathology
KW - Europe
KW - Female
KW - Hemodynamics
KW - Humans
KW - Male
KW - Microcirculation
KW - Percutaneous Coronary Intervention
KW - Predictive Value of Tests
KW - Recovery of Function
KW - Severity of Illness Index
KW - Transcatheter Aortic Valve Replacement
KW - Treatment Outcome
UR - http://www.scopus.com/inward/record.url?scp=85075494229&partnerID=8YFLogxK
U2 - 10.1161/CIRCINTERVENTIONS.119.008263
DO - 10.1161/CIRCINTERVENTIONS.119.008263
M3 - Article
C2 - 31752515
SN - 1941-7640
VL - 12
SP - e008263
JO - Circulation. Cardiovascular Interventions
JF - Circulation. Cardiovascular Interventions
IS - 12
M1 - e008263
ER -