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Pathophysiology, Diagnosis, and Treatment of Patients with Concomitant Severe Aortic Stenosis and Coronary Artery Disease: A Closer Look to the Unresolved Perplexity.

ABSTRACT: Degenerative aortic stenosis (AS) and coronary artery disease (CAD) are the most prevalent cardiovascular diseases in developed countries, and they coexist in up to 50% of patients. The pathophysiological rationale behind concomitant AS and CAD is discussed in detail in this review, together with prognostic implications. Detecting CAD in patients with AS may be challenging, as AS may mask the existence and symptoms of CAD. The safety and reliability of invasive and non-invasive physiological assessment for epicardial coronary disease are also a matter of debate. Finally, the selection and timing of optimal treatment of CAD in patients with severe AS are still unclear. Given the aging of the population, the increase in the prevalence of AS, and the ongoing paradigm shift in its treatment, controversies in the diagnosis and treatment of CAD in the setting of AS are deemed to grow in importance. In this paper, we present contemporary issues in the diagnosis and management of CAD in patients with severe AS who are transcatheter aortic valve implantation (TAVI) candidates and provide perspective on the treatment approach.

SUBMITTER: Di Gioia G

PROVIDER: S-EPMC8070187 | biostudies-literature | 2021 Apr

REPOSITORIES: biostudies-literature

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Pathophysiology, Diagnosis, and Treatment of Patients with Concomitant Severe Aortic Stenosis and Coronary Artery Disease: A Closer Look to the Unresolved Perplexity.

Di Gioia Giuseppe G Bartunek Jozef J Tesorio Tullio T Vukcevic Vladan V Aleksandric Srdjan S Dobric Milan M Franco Danilo D Barbato Emanuele E Banovic Marko M

Journal of clinical medicine 20210411 8

Degenerative aortic stenosis (AS) and coronary artery disease (CAD) are the most prevalent cardiovascular diseases in developed countries, and they coexist in up to 50% of patients. The pathophysiological rationale behind concomitant AS and CAD is discussed in detail in this review, together with prognostic implications. Detecting CAD in patients with AS may be challenging, as AS may mask the existence and symptoms of CAD. The safety and reliability of invasive and non-invasive physiological ass ...[more]

PMID: 33920349

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Project description:Background As younger patients are being considered for transcatheter aortic valve implantation (TAVI), the assessment and treatment of concomitant coronary artery disease is taking on increased importance. Methods and Results Thirteen contemporary lower-risk patients with TAVI with severe aortic stenosis (AS) and moderate-severe coronary lesions were included. Patients underwent assessment of coronary hemodynamics in the presence of severe AS (pre-TAVI), in the absence of severe AS (immediately post-TAVI), and at longer-term follow-up (6 months post-TAVI). Fractional flow reserve decreased from 0.85 (0.76-0.88) pre-TAVI to 0.79 (0.74-0.83) post-TAVI, and then to 0.71 (0.65-0.77) at 6-month follow-up (P<0.001 for all comparisons). Conversely, instantaneous wave-free ratio was not significantly different: 0.82 (0.80-0.90) pre-TAVI, 0.83 (0.77-0.88) post-TAVI, and 0.83 (0.73-0.89) at 6 months (P=0.735). These changes are explained by the underlying coronary flow. Hyperemic whole-cycle coronary flow (fractional flow reserve flow) increased from 26.36 cm/s (23.82-31.82 cm/s) pre-TAVI to 30.78 cm/s (29.70-34.68 cm/s) post-TAVI (P=0.012), to 40.20 cm/s (32.14-50.00 cm/s) at 6-month follow-up (P<0.001 for both comparisons). Resting flow during the wave-free period of diastole was not significantly different: 25.48 cm/s (21.12-33.65 cm/s) pre-TAVI, 24.54 cm/s (20.74-27.88 cm/s) post-TAVI, and 25.89 cm/s (22.57-28.96 cm/s) at 6 months (P=0.500). Conclusions TAVI acutely improves whole-cycle hyperemic coronary flow, with ongoing sustained improvements at longer-term follow-up. This enhanced response to hyperemic stimuli appears to make fractional flow reserve assessment less suitable for patients with severe AS. Conversely, resting diastolic flow is not significantly influenced by the presence of severe AS. Resting indices of coronary stenosis severity, therefore, appear to be more appropriate for this patient population, although large-scale prospective randomized trials will be required to determine the role of coronary physiology in patients with severe AS.

Project description:AimsCombined coronary artery bypass grafting (CABG) and aortic valve replacement (AVR), and female sex are associated with increased perioperative mortality in clinical risk scores. This study investigated male-female differences in short-term outcome stratified by age groups.Methods and resultsAll patients undergoing AVR and CABG between January 2001 and June 2021 at our institution were included. 1963 patients were grouped by decades into: 59 years and younger (n = 127), 60-69 (n = 471), 70-79 (n = 1070), and 80 years and older (n = 295). The primary end points of this study were 30 and 180 days mortality. Secondary end points were influence of preoperative risk factors and impact of sex on survival and postoperative major adverse events. Female patients showed higher 30 and 180 days mortality after combined CABG and AVR surgery (8.3% vs. 4.2%, P < 0.01; 15.8% vs. 9.4%, P < 0.01). Stratified by age groups, 30 and 180 days mortality remained significantly higher in septuagenarians (9.6% vs. 2.5%, P < 0.01; 16.3% vs. 7.7%, P < 0.01). Females were significantly older, had better preserved left ventricular function, and higher incidence of diabetes mellitus compared with male patients in this subgroup (P < 0.01; P = 0.01; P < 0.01). Additionally, females received significantly less internal mammary artery (IMA) conduits (P < 0.01). Female sex (OR: 3.33, 95% CI: [1.76-6.31]; 1.93, [1.22-3.06]), higher age (1.28, [1.13-1.45]; 1.16, [1.06-1.26]), diabetes mellitus (1.93, [1.03-3.60]; 1.70, [1.08-2.67]) and LVEF <30% (3.26, [1.48-7.17]; 2.23, [1.24-4.02]) were correlated with 30 and 180 days mortality, respectively. Upon multivariable testing, sex (1.77, [1.21-2.58]) and LVEF <30% (3.71, [2.39-5.76]) remained independent predictors for major adverse postoperative events. Infrequent use of IMA grafts was associated with increased 30 and 180 days mortality as well as adverse events (0.47, [0.25-0.87]; 0.46, [0.29-0.72]; 0.61, [0.42-0.88]).ConclusionsSex disparities in baseline characteristics may delay operative intervention in female patients. The inherent risk profiles might be responsible for outcome differences in septuagenarians.

Dataset Information

Pathophysiology, Diagnosis, and Treatment of Patients with Concomitant Severe Aortic Stenosis and Coronary Artery Disease: A Closer Look to the Unresolved Perplexity.

Publications

Pathophysiology, Diagnosis, and Treatment of Patients with Concomitant Severe Aortic Stenosis and Coronary Artery Disease: A Closer Look to the Unresolved Perplexity.

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