The impact of chronic total occlusions in patient outcomes after transcatheter aortic valve implantation: a systematic review and meta-analysis

Abstract Introduction The presence of chronic total occlusions (CTO) can be a significant predictor of outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). Despite this relationship is poorly understood in current literature, evaluating its significance is of major importance, as it could lead to novel indications for coronary interventions in this patient phenotype, and especially determine the optimal timepoint for revascularization. Purpose The aim of this systematic review and meta-analysis is to investigate the impact of CTOs in mortality and adverse in patients undergoing TAVI. Methods A systematic search in 3 different databases (MEDLINE/PubMed, Web of Science and Scopus) was conducted. After selecting all appropriate trials according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a random effect meta-analysis was performed. Results A total of 5 studies were included, with a total population of 35,902 patients, out of which 5,867 had a CTO (CTO-TAVI) and 30,035 did not (non-CTO-TAVI). There was no significant difference between the two cohorts regarding in-hospital Relative Risk (RR): 1.15; 95% Confidence Interval (95%CI): 0.73-1.80 or 1-year all-cause mortality (RR: 1.55; 95%CI: 0.79-3.04). Furthermore, CTO-TAVI was associated with significantly lower rates of post intervention pacemaker implantation (RR: 0.88, 95%CI: 0.79-0.97), whilst non-CTO-TAVI with lower acute myocardial infarction (AMI) events (RR: 1.32, 95%CI: 1.10-1.59). No differences were found in respect to cardiogenic shock (RR: 1.17, 95%CI: 0.96-1.43), acute kidney injury (RR: 1.13, 95%CI: 0.90-1.43) or bleeding events (RR: 1.04, 95%CI: 0.90-1.20). Finally, regarding all death events at 1 year, evaluated at each study’s last follow up, there was still no significant difference between the two cohorts (RR: 1.26, 95%CI: 0.90-1.75). Conclusion This metanalysis shows that there is no difference in mortality in patients undergoing TAVI, irrespective of CTO presence. Furthermore, CTO-TAVI is associated with significantly lower new pacemaker implantation and increased AMIs, with no other differences in adverse outcomes. Therefore, these findings suggest a modest effect of CTO-TAVI in post-operative adverse events or mortality. However, the observational design of the included studies and the limited available data warrant further research of the CTO-TAVI relationship in larger, randomized clinical trials.