Impact of Coronary Diameter Stenosis and Proximal Lesion Location on Outcomes Following PCI in Patients Undergoing TAVI: Prespecified NOTION-3 Substudy

BACKGROUND: Optimal treatment of coronary artery disease in patients undergoing transcatheter aortic valve implantation remains debated. Here, our aim was to analyze the impact of the diameter and location of coronary stenosis on outcomes in patients undergoing percutaneous coronary intervention (PCI) with transcatheter aortic valve implantation. METHODS: This study was a prespecified subanalysis of the NOTION-3 trial (Nordic Aortic Valve Intervention), which randomized patients with severe symptomatic aortic stenosis and physiologically significant stable coronary artery disease to receive either PCI or conservative treatment of coronary artery disease with transcatheter aortic valve implantation. In this substudy, patients were stratified according to diameter stenosis (<90% or ≥90%) and stenosis location (proximal or nonproximal). The primary outcome was major adverse cardiovascular events, a composite of all-cause death, myocardial infarction, and urgent revascularization. RESULTS: Of 455 randomized patients, 184 (40%) had diameter stenosis <90% and 271 (60%) ≥90%. A total of 294 (65%) patients had at least 1 proximal stenosis, while in 161 (35%) patients, stenoses were nonproximal. At a median follow-up of 2 years (interquartile range, 1–4), PCI reduced the absolute risk of major adverse cardiovascular event by 13% in patients with diameter stenosis ≥90% (PCI 24% versus conservative treatment 37%; hazard ratio, 0.53 [95% CI, 0.34–0.82]), whereas no benefit was observed in patients with diameter stenosis <90% (31% versus 33%; hazard ratio, 1.04 [95% CI, 0.62–1.73]; P for interaction=0.051). PCI reduced major adverse cardiovascular events in case of proximal stenosis (26% versus 38%; hazard ratio, 0.61 [95% CI, 0.40–0.93]), although the difference in effect remained nonsignificant when compared with patients with nonproximal stenosis (28% versus 32%; hazard ratio, 0.91 [95% CI, 0.52–1.61]; P for interaction=0.27). CONCLUSIONS: The beneficial effect of PCI in patients undergoing transcatheter aortic valve implantation with physiologically significant stable coronary artery disease was seemingly pronounced in patients with high-grade stenosis, while stenosis location was not found to modify the outcome despite an almost similar beneficial effect with PCI in patients with proximal stenosis.