Percutaneous Aortic Valve Implantation in Patients with Coronary Artery Disease: Review of Therapeutic Strategies
- Volume 21 - Issue 12 - December, 2009
- Posted on: 12/7/09
- 0 Comments
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In this report, we described a single-stage procedure wherein PCI was immediately followed by PAVI. This method is advantageous in that it may considerably decrease the total hospitalization time, a major source of morbidity in elderly patients. Decreasing the hospital stay will probably decrease the total cost of the procedure and reimbursement, which is appealing for the medical providers. Moreover, since PCI is often a high-risk procedure in patients with aortic stenosis, by lowering the gradients along the aortic valve soon after performing PCI, one can hypothesize that the long-term outcome of the PCI might be improved. However, there are not enough data on the safety of performing the single-stage procedure. One of the disadvantages is the risk of coronary stent thrombosis during the intervals of reduced coronary flow while performing rapid ventricular pacing, or the risk of performing urgent cardiopulmonary bypass due to complication in these high-risk patients. On the basis of these findings, we have developed an algorithm for the treatment of CAD in a PAVI candidate (using either a transfemoral or transapical approach) (Figure 3). First the physician should assess the coronary arteries and/or bypass vessels. If there is no significant obstruction in a major coronary segment, PAVI should be performed without delay.
In a case where there is a significant obstruction in a major coronary segment, the team should evaluate the complexity of performing complete revascularization by PCI. In a case where the patient has significant coronary disease, but the disease is not anticipated to be unduly complex for revascularization using PCI, the team needs to decide when to perform the PAVI procedure: immediately after the PCI (single-stage procedure) or several days or even weeks apart (multistage procedure), taking the relative advantages of each as well as the patient’s wellbeing into account.
When the PCI seems high-risk and/or complex, the team should reassess the patient’s surgical risk. If that risk is not extremely high, the decision should be to pursue bypass and aortic-valve replacement surgery. “Off-pump” bypass surgery, combined with PAVI or other hybrid procedures, should be considered depending on the technical feasibility and/or medical center’s expertise.12 If the surgical risk seems very high, then PCI followed by PAVI (staged or during a single session) should be considered. Alternatively, in this high-risk setting, the team should consider performing only partial coronary revascularization and/or aortic-valve balloon valvuloplasty possibly as a temporary or bridge treatment before PAVI.
An operator performing PCI in a candidate for PAVI also needs to decide whether to implant a stent and what type of stent should be used. Bare-metal stents significantly increase the need for repeat intervention at the stent site which, in some cases, means crossing the valve stent struts during PAVI. However, drug-eluting stents are limited by the need for long-term dual antiplatelet therapy with a somewhat augmented risk of bleeding — an especially important consideration in current PAVI candidates who are usually frail patients with many co-morbidities. No matter which coronary stent is chosen, every effort should be taken to ensure that the implanted valve will allow future engagement of the coronary arteries.
Conclusion. In summary, there are many different treatment options for combined CAD and severe aortic stenosis in candidates for PAVI. We have developed an algorithm that may help decision-making while approaching this common clinical scenario.