State-of-the-Art Review
Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis

https://doi.org/10.1016/j.jcin.2021.07.058Get rights and content
Under an Elsevier user license
open archive

Highlights

  • The coexistence of epicardial CAD among patients with AS is common.

  • Diagnostic and treatment alternatives remain ambiguous and highly debated.

  • Physiological changes of AS on hemodynamic status challenge assessment of concomitant CAD.

  • Studies evaluating the efficacy of revascularization in patients with AS are needed.

Abstract

Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist, with up to two thirds of patients with AS having significant CAD. Given the challenges when both disease states are present, these patients require a tailored approach diagnostically and therapeutically. In this review the authors address the impact of AS and aortic valve replacement (AVR) on coronary hemodynamic status and discuss the assessment of CAD and the role of revascularization in patients with concomitant AS and CAD. Remodeling in AS increases the susceptibility of myocardial ischemia, which can be compounded by concomitant CAD. AVR can improve coronary hemodynamic status and reduce ischemia. Assessment of the significance of coexisting CAD can be done using noninvasive and invasive metrics. Revascularization in patients undergoing AVR can benefit certain patients in whom CAD is either prognostically or symptomatically important. Identifying this cohort of patients is challenging and as yet incomplete. Patients with dual pathology present a diagnostic and therapeutic challenge; both AS and CAD affect coronary hemodynamic status, they provoke similar symptoms, and their respective treatments can have an impact on both diseases. Decisions regarding coronary revascularization should be based on understanding this complex relationship, using appropriate coronary assessment and consensus within a multidisciplinary team.

Key Words

aortic stenosis
chronic coronary syndromes
coronary artery disease
coronary hemodynamic status
revascularization

Abbreviations and Acronyms

ADAS
acute decompensated aortic stenosis
AS
aortic stenosis
CABG
coronary artery bypass grafting
CAD
coronary artery disease
CT
computed tomography
CFR
coronary flow reserve
DAPT
dual-antiplatelet therapy
FFR
fractional flow reserve
iFR
instantaneous wave-free ratio
LV
left ventricular
LVH
left ventricular hypertrophy
PCI
percutaneous coronary intervention
PPM
patient-prosthesis mismatch
SAVR
surgical aortic valve replacement
TAVR
transcatheter aortic valve replacement

Cited by (0)

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.