Author + information
- Francesco Pollari, MD, PhD∗ (, )
- Theodor Fischlein, MD and
- Steffen Pfeiffer, MD
- ↵∗Department of Cardiac Surgery, Cardiovascular Center, Klinikum Nürnberg, Paracelsus Medical University, Breslauer Strasse 201, 90471 Nuremberg, Germany
We are grateful to Vilalta et al. (1) for enlightening the faith of patients with coronary artery disease (CAD) undergoing transcatheter aortic valve replacement (TAVR). As we interpret the data and findings: TAVR does not prevent acute coronary syndromes (ACS), in particular in patients with pre-existing CAD. The study highlighted some very interesting findings, which deserve further discussion.
ACS patients were younger than non-ACS patients. Moreover, ACS patients had significantly lower pre-operative mean gradients, which should be a protective factor against left ventricular hypertrophy leading to myocardial oxygen supply demand mismatch, one potential reason for type 2 non–ST-segment elevation myocardial infarction (NSTEMI). Do the authors have an explanation for these findings? More than one-third of ACS patients presented with type 2 NSTEMI, with a very high incidence during the first year after TAVR (50%). Indeed, the present study followed the patients starting from 1 month after the procedure, but only the cumulative incidence of the first year is reported. (Postprocedural?) anemia accounted for almost 18% of type 2 NSTEMIs. Heart failure, infection, and atrial fibrillation were mentioned as the other causes and usually occurred early after the procedure. Nontransfemoral (we infer mainly transapical TAVR [TA-TAVR]) access was found to be a risk factor for ACS. In our experience, based on more than 1,200 TAVR procedures, the TA-TAVR leads to increased levels of troponin T that can persist up to 30 days after the procedure. This permanence above the 99th percentile of troponin is generally isolated, without other signs and symptoms, and is due to the myocardial injury intrinsic to the surgical technique. We fear that this fact could lead to an overestimation of the real incidence of ACS, especially if patients with suspected ACS are admitted in different institutions from where the TAVR was performed, and so the comparison with previous troponin values as well as previous electrocardiograms is not possible. Indeed, in a recent study of our group, we found anomalies in baseline electrocardiograms in up to 88% of patients receiving a TAVR (2).
In summary, and also supported by Table 4 of the paper (1), no significant difference was noted between PCI procedures pre- and post-TAVR, most likely reflecting the natural course of CAD in elderly patients, independent from coexisting aortic valve disease. This again supports our statement at the beginning: The treatment of coexisting aortic valve disease by TAVR does not change the risk of ACS during follow-up.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2019 American College of Cardiology Foundation
- Vilalta V.,
- Asmarats L.,
- Ferreira-Neto A.N.,
- et al.
- Pollari F.,
- Großmann I.,
- Vogt F.,
- et al.