Long‐Term Effects of Transcatheter Aortic Valve Implantation on Coronary Hemodynamics in Patients With Concomitant Coronary Artery Disease and Severe Aortic Stenosis

<jats:sec xml:lang="en"> <jats:title>Background</jats:title> <jats:p xml:lang="en">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.</jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Methods and Results</jats:title> <jats:p xml:lang="en"> 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‐ <jats:styled-content style="fixed-case">TAVI</jats:styled-content> ), in the absence of severe AS (immediately post‐ <jats:styled-content style="fixed-case">TAVI</jats:styled-content> ), and at longer‐term follow‐up (6 months post‐ <jats:styled-content style="fixed-case">TAVI</jats:styled-content> ). Fractional flow reserve decreased from 0.85 (0.76–0.88) pre‐ <jats:styled-content style="fixed-case">TAVI</jats:styled-content> to 0.79 (0.74–0.83) post‐ <jats:styled-content style="fixed-case">TAVI</jats:styled-content> , and then to 0.71 (0.65–0.77) at 6‐month follow‐up ( <jats:italic>P</jats:italic> <0.001 for all comparisons). Conversely, instantaneous wave‐free ratio was not significantly different: 0.82 (0.80–0.90) pre‐ <jats:styled-content style="fixed-case">TAVI</jats:styled-content> , 0.83 (0.77–0.88) post‐ <jats:styled-content style="fixed-case">TAVI</jats:styled-content> , and 0.83 (0.73–0.89) at 6 months ( <jats:italic>P</jats:italic> =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‐ <jats:styled-content style="fixed-case">TAVI</jats:styled-content> to 30.78 cm/s (29.70–34.68 cm/s) post‐ <jats:styled-content style="fixed-case">TAVI</jats:styled-content> ( <jats:italic>P</jats:italic> =0.012), to 40.20 cm/s (32.14–50.00 cm/s) at 6‐month follow‐up ( <jats:italic>P</jats:italic> <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‐ <jats:styled-content style="fixed-case">TAVI</jats:styled-content> , 24.54 cm/s (20.74–27.88 cm/s) post‐ <jats:styled-content style="fixed-case">TAVI</jats:styled-content> , and 25.89 cm/s (22.57–28.96 cm/s) at 6 months ( <jats:italic>P</jats:italic> =0.500). </jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Conclusions</jats:title> <jats:p xml:lang="en"> <jats:styled-content style="fixed-case">TAVI</jats:styled-content> 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. </jats:p> </jats:sec>