Orbital Atherectomy for Calcific Coronary Artery Disease in Patients With Severe Aortic Stenosis: A Safety and Feasibility Study

Abstract

BACKGROUND: Percutaneous revascularization followed by transcatheter aortic valve replacement (TAVR) has been increasingly utilized as an alternative to surgery in patients with severe aortic stenosis (AS) and coronary artery disease (CAD). In many of these patients, the coronary arteries are severely calcified and may best be treated with atherectomy; however, atherectomy is not routinely performed in severe AS patients due to safety concerns. There is a paucity of data on the safety of orbital atherectomy (OA) in patients with severe AS and concurrent calcific CAD. METHODS: We retrospectively analyzed the medical records of all patients with severe AS who underwent OA-facilitated percutaneous coronary intervention (PCI) at our center between September 1, 2015 and November 1, 2018. RESULTS: Twenty-four patients (mean age, 82.5 +/- 7.6 years) were identified. Mean aortic valve area was 0.68 +/- 0.26 cm and mean aortic valve gradient was 43 +/- 17.7 mm Hg. All PCIs were successful (mean diameter stenosis, 80.8 +/- 11%; mean number of passes, 5.3 +/- 3.3). Two patients had planned hemodynamic support, with left ventricular assist device and intra-aortic balloon pump; none of the patients required vasopressors during PCI. There was a slight reduction in heart rate during OA (71.6 bpm vs 63.3 bpm; P=.02), with no major procedure-related clinical events. Only 1 patient (4.2%) with pre-existing conduction system disease required transient pacing from his permanent pacemaker during OA. All procedures were completed successfully and there were no periprocedural deaths or clinical myocardial infarctions. CONCLUSION: OA-facilitated PCI can be safely performed in patients with severe AS and severely calcified CAD with low risk of complications. There was no significant change in blood pressure and heart rate during OA, with minimal need for temporary pacing.