ST-Segment Elevation Myocardial Infarction Following Transcatheter Aortic Valve Replacement

J Am Coll Cardiol. 2021 May 4;77(17):2187-2199. doi: 10.1016/j.jacc.2021.03.014.

Abstract

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.

Keywords: ST-segment elevation myocardial infarction; acute coronary syndrome; mortality; percutaneous coronary intervention; transcatheter aortic valve replacement.

Publication types

  • Multicenter Study

MeSH terms

  • Aged, 80 and over
  • Aortic Valve Stenosis / surgery*
  • Coronary Angiography
  • Female
  • Follow-Up Studies
  • Global Health
  • Hospital Mortality / trends
  • Humans
  • Incidence
  • Male
  • Percutaneous Coronary Intervention
  • Postoperative Complications / epidemiology
  • Postoperative Complications / etiology*
  • Risk Assessment / methods*
  • Risk Factors
  • ST Elevation Myocardial Infarction / diagnosis
  • ST Elevation Myocardial Infarction / epidemiology
  • ST Elevation Myocardial Infarction / etiology*
  • Time Factors
  • Transcatheter Aortic Valve Replacement / adverse effects*