DOI: 10.1097/mca.0000000000001687 ISSN: 0954-6928

Percutaneous coronary intervention or medical therapy alone before transcatheter aortic valve replacement: insights from a meta-analysis of randomized trials

Ahmed Elmorsy Mohamed, Mustafa Abomohsen, Muhammad Haisum Maqsood, Abdul Hakim Almakadma, Zeyad Kholeif, Ahmed Farid Gadelmawla, Rafael Harari, Susheel K. Kodali, Islam Y. Elgendy, Sripal Bangalore
Show PDF Cite

Background

Coronary artery disease frequently coexists in patients undergoing transcatheter aortic valve replacement (TAVR), yet the benefit of routine percutaneous coronary intervention (PCI) before TAVR remains uncertain.

Objectives

To evaluate the efficacy and safety of routine PCI before TAVR compared with conservative or deferred revascularization.

Methods

We pooled randomized clinical trials comparing PCI before TAVR versus no/deferred PCI in patients with concomitant coronary artery disease. Random-effects models estimated pooled relative risks (RRs) with 95% confidence intervals (CIs). Bayesian sensitivity analyses and trial sequential analysis were performed.

Results

Three trials included 1156 patients (PCI, n = 579; no/deferred PCI, n = 577). In comparator arms reporting postrandomization PCI/revascularization, 72 of 461 patients (15.6%) underwent subsequent PCI/revascularization. PCI did not significantly reduce major adverse cardiac events (RR: 0.91, 95% CI: 0.70–1.18; I 2 = 36.9%), myocardial infarction (RR: 0.86, 95% CI: 0.45–1.63; I 2 = 49.8%), all-cause death (RR: 0.90, 95% CI: 0.70–1.15; I 2 = 0.0%), or stroke (RR: 0.70, 95% CI: 0.48–1.03; P = 0.069; I 2 = 0.0%). In two trials, PCI reduced urgent revascularization (RR: 0.33, 95% CI: 0.13–0.87; I 2 = 54.5%) but increased major bleeding (RR: 1.57, 95% CI: 1.07–2.32; I 2 = 37.9%) and any bleeding (RR: 1.77, 95% CI: 1.27–2.47; I 2 = 66.7%). Bayesian analyses were directionally concordant. Trial sequential analysis was inconclusive for all efficacy outcomes.

Conclusion

Routine PCI before TAVR reduced urgent revascularization but increased bleeding, without significant differences in other outcomes. Current evidence remains underpowered to rule out benefit for other ischemic outcomes; larger trials are needed.

More from our Archive