Incidence, Management and Impact of Incidental Coronary Artery Disease on Outcomes Following Transcatheter Aortic Valve Implantation

Background: Coronary artery disease (CAD) and aortic stenosis commonly coexist. However, whether treatment of asymptomatic incidental CAD prior to transcatheter aortic valve implantation (TAVI) improves outcomes remains uncertain. Methods: We analysed data from 338 patients undergoing TAVI for symptomatic severe aortic stenosis between 2008 to 2018 to assess whether CAD (defined as coronary artery stenosis ≥50% in ≥1 vessel) management prior to TAVI reduced post procedure myocardial injury (PPMI; defined as troponin-I 15x the upper limit of normal within 24 hours) or affected 30-day and 12-month MACCE or 2-year survival. Those with previous coronary artery bypass grafting were excluded. Results: Incidental CAD was identified in 41% (140) of patients during work-up for TAVI; mean age 83 ± 7 years; 51% female. Male gender (66% vs. 37%, p < 0.01) and presence of insulin-dependent diabetes (8% vs. 3%, p = 0.02) were associated with incidental CAD. Of those with incidental CAD, 36% (51) proceeded to pre-TAVI PCI, while 64% (89) were managed medically. Those managed with PCI had more severe CAD as determined by Gensini score (median 24, IQR 15-36 vs. 15, IQR 10-22, p < 0.01). PPMI (61% vs. 67%, p = 0.47), 30-day MACCE (2% vs. 6%, p = 0.26), 12 month MACCE (16% vs 29%, p = 0.13) and two-year mortality (11% vs. 6%, p = 0.42), were similar between patients who were medically managed versus PCI. Conclusion: Male patients with insulin dependent diabetes are more likely to have incidental asymptomatic coronary artery disease found during TAVI work-up. Revascularisation of incidental CAD with PCI was not associated with increased PPMI or adverse clinical outcomes.