Commentary: "One for the money, two for the show, or two for the money, one for the show?"

Frank A. Baciewicz, Jr, MD

Concomitant PCI/TAVR will likely increase compared with early or late staged PCI/TAVR but remains less frequent than SAVR/CABG.

See Article page 148.

The Carl Perkins intro “One for the Money, Two for the Show” in the 1955 classic song “Blue Suede Shoes” was not a commentary on concomitant versus staged percutaneous coronary intervention (PCI)/transcatheter aortic valve replacement (TAVR). However, early or late staged PCI/TAVR provides 2 reimbursable procedures (“Two for the Money”) whereas concomitant PCI/TAVR is akin to “One for the Show.” Tran and colleagues, in their article “Staged versus Concomitant Transcatheter Aortic Valve Replacement and Percutaneous Coronary Intervention: A National Analysis,” compare early staged PCI/TAVR (performed during the same hospitalization) with concomitant PCI/TAVR (performed on the same day) and late staged PCI/TAVR (performed during different hospitalizations) during 2016 to 2018.

The data were retrospectively collected from the National Readmission Database, which comprises approximately 60% of American hospitalizations. The Society of Thoracic Surgeons/American College of Cardiology Registry of TAVR showed 72,000 TAVR procedures performed in 2019. Patel and colleagues noted a PCI rate of roughly 35 per thousand TAVR or 3.5% PCI/TAVR during the same hospitalization in 2015 to 2018. Since the Readmission Database focused on 161,346 patients who underwent TAVR from 2015 to 2018 and various iterations of PCI/TAVR rate ranged from 3.18% to 4.76% rate, the data collection appears representative of the US pattern.

The authors note that concomitant PCI/TAVR was performed in patients with fewer comorbidities, for less cost, for a shorter total length of stay, with similar mortality, and with only 5% or significantly less acute kidney injury (AKI). The study by Patel and colleagues of same hospitalization PCI/TAVR demonstrated a 24.67% AKI rate.

The decreased incidence of AKI is initially surprising, but the concomitant PCI/TAVR cohort was exclusively elective, which allowed strategizing contrast use and had only single-vessel coronary disease. Correcting the severe aortic stenosis on the same day as administering the contrast load may have allowed improved renal perfusion to counteract the contrast effect. In addition, one less trip to the cath lab may result in fewer hypotensive episodes, which leads to less AKI. With the concomitant PCI/TAVR group's average total length of stay at 2 days compared with an average 11- and 8-day total lengths of stay for early and late staged PCI/TAVR, respectively, there were fewer lab draws to test for acute AKI. Also, with significantly more discharges to home in the concomitant PCI/TAVR group, there are more chances to miss subclinical episodes of AKI.

The authors report 3 days as the mean between PCI and TAVR in the early staged cohort. However, there may be a correlation in the early staged PCI/TAVR group with the number of coronaries stented and/or the number of days between procedures and the AKI rate. The late staged PCI/TAVR were done an average of 32 days following discharge, so the interval between contrast exposures was likely not a factor in that group.

The incidence of any outcomes may be underrepresented in the late staged PCI/TAVR cohort, since patients having PCI in November/December were removed from the study due to the inability for same calendar year follow-up.

Over the 3-year study interval, the percentage of patients in the early staged group remained constant. Meanwhile, the concomitant PCI/TAVR increased from 11.8% to 16.8%, whereas the late staged PCI/TAVR decreased from 75.2% to 69.5%. Given the data provided, the trend to concomitant PCI/TAVR should be expected to increase. Could the percent concomitant cohort in this study have been decreased by patients who were initially planned for concomitant PCI/TAVR, but because of excessive contrast use with multiple vessel coronary disease or other technical issues were converted to early or late staged PCI/TAVR?

It would be informative to know the number of single-vessel PCI/TAVR in which the single vessel was the ostial left anterior descending (LAD) or had previous coronary artery bypass grafting (CABG). I would argue that surgical aortic valve replacement (SAVR) SAVR/CABG with a left internal mammary artery to the LAD is an unbeatable combination unless there were significant comorbidities, or the case was a re-do with intact left internal mammary artery to the LAD.

One should also have perspective in that more than 15,000 SAVR/CABGS were performed in the United States in 2018. The total number of PCI/TAVR in the National Readmission Database compilation included only 5843 patients over 2016 to 2018. Nevertheless, the “gold standard” of SAVR/CABG for severe aortic stenosis and coronary artery disease may begin to have competition. Approval of TAVR for low-risk surgery patients in 2019 who also have a single involved coronary other than the LAD may move the needle. The trends for PCI/TAVR versus SAVR/CABG will be interesting to chart.

As interventional techniques evolve, and new contrast agents with less renal effects are introduced, will PCI/TAVR remain a staged procedure (“Two for the Money”) or more commonly become a concomitant procedure (“One for the Show”)?