CirculationReview
17 Dec 2024
Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist and share pathophysiological mechanisms. The proportion of patients with AS and CAD requiring revascularization varies widely because of uncertainty about best clinical practices.
Although combined surgical aortic valve replacement and coronary artery bypass grafting has been the standard of care, management options in patients with AS and CAD requiring revascularization have expanded with the advent of transcatheter aortic valve replacement (TAVR).
Potential alternative treatment pathways include revascularization before TAVR, concomitant TAVR and percutaneous coronary intervention, percutaneous coronary intervention after TAVR and deferred percutaneous coronary intervention or hybrid procedures.
Selection depends on underlying disease severity, antithrombotic treatment strategies, clinical presentation, and symptom evolution after TAVR.
In patients undergoing surgical aortic valve replacement, the addition of coronary artery bypass grafting has been associated with improved long-term mortality, especially if CAD is complex. although it is associated with higher periprocedural risk.
The therapeutic impact of percutaneous coronary intervention in patients with TAVR is less well-established. The multitude of clinical permutations and remaining uncertainties do not support a uniform treatment strategy for patients with AS and CAD.
Therefore, to provide the best possible care for each individual patient, heart teams need to be familiar with the available data on AS and CAD.
Herein, we provide an in-depth review of the evidence supporting the decision-making process between transcatheter and surgical approaches and the key elements of treatment selection in patients with AS and CAD.
Dr Windecker reports research and educational grants to the institution from Abbott, Amgen, AstraZeneca, BMS, Bayer, Biotronik, Boston Scientific, Cardinal Health, CardioValve, CSL Behring, Daiichi Sankyo, Edwards Lifesciences, Guerbet, InfraRedx, Johnson & Johnson, Medicure, Medtronic, Novartis, Polares, OrPha Suisse, Pfizer, Regeneron, Sanofi-Aventis, Sinomed, Terumo, and V-Wave. Dr Windecker serves as unpaid advisory board member or unpaid member of the steering/executive group of trials funded by Abbott, Abiomed, Amgen, AstraZeneca, BMS, Boston Scientific, Biotronik, Cardiovalve, Edwards Lifesciences, Med Alliance, Medtronic, Novartis, Polares, Sinomed, V-Wave, and Xeltis, but has not received personal payments by pharmaceutical companies or device manufacturers. He is also member of the steering/executive committee group of several investigator-initiated trials that receive funding by industry without impact on his personal remuneration. Dr Reineke reports travel expenses from Abbott, Edwards Lifesciences, and Medtronic and has proctor and consulting contracts with Abbott and Medtronic. Dr Lanz reports speaker fees to the institution from Edwards Lifesciences and Abbott. Dr De Backer reports institutional research grants and personal consulting fees from Abbott, Boston Scientific, and Medtronic. Dr Borger reports that his hospital receives speakers’ honoraria or consulting fees on his behalf from Edwards Lifesciences, Medtronic, Abbott, and Artivion. Dr Pilgrim reports research grants to the institution from Edwards Lifesciences, Boston Scientifc, Biotronik, Medtronic, and Abbott, and personal fees from Biotronik and HighLife SAS. The other authors report no conflicts.
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