ST-Segment Elevation Myocardial Infarction Following Transcatheter Aortic Valve Replacement

Laurent Faroux, Thibault Lhermusier, Flavien Vincent, Luis Nombela-Franco, Didier Tchétché, Marco Barbanti, Mohamed Abdel-Wahab, Stephan Windecker, Vincent Auffret, Diego Carter Campanha-Borges, Quentin Fischer, Erika Muñoz-Garcia, Ramiro Trillo-Nouche, Troels Jorgensen, Vicens Serra, Stefan Toggweiler, Giuseppe Tarantini, Francesco Saia, Eric Durand, Pierre Donaint, Enrique Gutierrez-Ibanes, Harindra C Wijeysundera, Gabriela Veiga, Giuseppe Patti, Fabrizio D'Ascenzo, Raul Moreno, Christian Hengstenberg, Chekrallah Chamandi, Lluis Asmarats, Rosana Hernandez-Antolin, Joan Antoni Gomez-Hospital, Juan Gabriel Cordoba-Soriano, Uri Landes, Victor Alfonso Jimenez-Diaz, Ignacio Cruz-Gonzalez, Mohammed Nejjari, François Roubille, Éric Van Belle, German Armijo, Saifullah Siddiqui, Giuliano Costa, Sameh Elsaify, Thomas Pilgrim, Hervé le Breton, Marina Urena, Antonio Jesus Muñoz-Garcia, Lars Sondergaard, Montserrat Bach-Oller, Chiara Fraccaro, Hélène Eltchaninoff, Damien Metz, Maria Tamargo, Victor Fradejas-Sastre, Andrea Rognoni, Francesco Bruno, Georg Goliasch, Marcelo Santaló-Corcoy, Jesus Jimenez-Mazuecos, John G Webb, Guillem Muntané-Carol, Jean-Michal Paradis, Antonio Mangieri, Henrique Barbosa Ribeiro, Francisco Campelo-Parada, Josep Rodés-Cabau
Journal of the American College of Cardiology 2021 May 4, 77 (17): 2187-2199

BACKGROUND: Among patients with acute coronary syndrome following transcatheter aortic valve replacement (TAVR), those presenting with ST-segment elevation myocardial infarction (STEMI) are at highest risk.

OBJECTIVES: The goal of this study was to determine the clinical characteristics, management, and outcomes of STEMI after TAVR.

METHODS: This was a multicenter study including 118 patients presenting with STEMI at a median of 255 days (interquartile range: 9 to 680 days) after TAVR. Procedural features of STEMI after TAVR managed with primary percutaneous coronary intervention (PCI) were compared with all-comer STEMI: 439 non-TAVR patients who had primary PCI within the 2 weeks before and after each post-TAVR STEMI case in 5 participating centers from different countries.

RESULTS: Median door-to-balloon time was higher in TAVR patients (40 min [interquartile range: 25 to 57 min] vs. 30 min [interquartile range: 25 to 35 min]; p = 0.003). Procedural time, fluoroscopy time, dose-area product, and contrast volume were also higher in TAVR patients (p < 0.01 for all). PCI failure occurred more frequently in patients with previous TAVR (16.5% vs. 3.9%; p < 0.001), including 5 patients in whom the culprit lesion was not revascularized owing to coronary ostia cannulation failure. In-hospital and late (median of 7 months [interquartile range: 1 to 21 months]) mortality rates were 25.4% and 42.4%, respectively (20.6% and 38.2% in primary PCI patients), and estimated glomerular filtration rate <60 ml/min (hazard ratio [HR]: 3.02; 95% confidence interval [CI]: 1.42 to 6.43; p = 0.004), Killip class ≥2 (HR: 2.74; 95% CI: 1.37 to 5.49; p = 0.004), and PCI failure (HR: 3.23; 95% CI: 1.42 to 7.31; p = 0.005) determined an increased risk.

CONCLUSIONS: STEMI after TAVR was associated with very high in-hospital and mid-term mortality. Longer door-to-balloon times and a higher PCI failure rate were observed in TAVR patients, partially due to coronary access issues specific to the TAVR population, and this was associated with poorer outcomes.

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