Staged Complete Revascularization for Coronary Artery Disease vs Medical Management Alone in Patients With AS Undergoing Transcatheter Aortic Valve Replacement
- Conditions
- Coronary StenosisAortic StenosisCoronary Artery Disease
- Interventions
- Procedure: Percutaneous Coronary Intervention (PCI)
- Registration Number
- NCT04634240
- Lead Sponsor
- University of British Columbia
- Brief Summary
Patients undergoing transcatheter aortic valve replacement (TAVR) often have concomitant coronary artery disease (CAD) which may adversely affect prognosis. There is uncertainty about the benefits and the optimal timing of revascularization for such patients. There is currently clinical equipoise regarding the management of concomitant CAD in patients undergoing TAVR. Some centers perform routine revascularization with percutaneous coronary intervention (PCI) (either before or after TAVR), while others follow an alternative strategy of medical management.
The potential benefits and optimal timing of PCI in these patients are unknown. As TAVR expands to lower risk patients, and potentially becomes the preferred therapy for the majority of patients with severe aortic stenosis, the optimal management of concomitant coronary artery disease will be of increasing importance.
The COMPLETE TAVR study will determine whether, on a background of guideline-directed medical therapy, a strategy of complete revascularization involving staged PCI using drug eluting stents to treat all suitable coronary artery lesions is superior to a strategy of medical therapy alone in reducing the composite outcome of Cardiovascular Death, new Myocardial Infarction, Ischemia-driven Revascularization or Hospitalization for Unstable Angina or Heart Failure.
The study will be a randomized, multicenter, open-label trial with blinded adjudication of outcomes. Patients will be screened and consented for elective transfemoral TAVR and randomized within 96 hours of successful balloon expandable TAVR.
Complete Revascularization:
Staged PCI using third generation drug eluting stents to treat all suitable coronary artery lesions in vessels that are at least 2.5 mm in diameter and that are amenable to treatment with PCI and have a ≥70% visual angiographic diameter stenosis. Staged PCI can occur any time from 1 to 45 days post successful transfemoral TAVR.
Vs. Medical Therapy Alone:
No further revascularization of coronary artery lesions.
All patients, regardless of randomized treatment allocation, will receive guideline-directed medical therapy consisting of risk factor modification and use of evidence-based therapies. The COMPLETE TAVR study will help address the current lack of evidence in this area. It will likely impact both the global delivery of health care and the management and clinical outcomes of all patients undergoing TAVR with concomitant CAD.
- Detailed Description
Not available
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 4000
- Symptomatic aortic valve stenosis prior to TAVR (NYHA Functional Class ≥ 2 OR Abnormal exercise test with severe SOB, abnormal BP response, or arrhythmia)
AND
- CAD defined as: at least 1 coronary artery lesion of ≥70% visual angiographic diameter stenosis in a native segment ≥2.5 mm in diameter that is not a CTO and is amenable to treatment with PCI
AND
- Consensus by the Local Multidisciplinary Heart Team that the patient is suitable for elective transfemoral TAVR with a balloon expandable transcatheter heart valve AND would receive a bypass with an anastomosis distal to the coronary artery lesion(s) if they were undergoing SAVR.
Local Multidisciplinary Heart Teams are expected to follow current clinical guidelines for selection of patients for TAVR with an eligible patient generally expected to have:
[AVA ≤ 1.0 cm2 OR AVA index ≤ 0.6 cm2/m2]
OR
[Jet velocity ≥ 4.0 m/s OR mean gradient ≥ 40 mmHg]
OR
patients without these criteria may undergo TAVR if the Local Multidisciplinary Heart Team concludes it is appropriate.
AND
- Successful transfemoral TAVR, defined as the implantation of a single transcatheter aortic valve within the past 96 hours with freedom from more than minimal aortic insufficiency, stroke, or major vascular complications.
- PCI already performed within 90 days prior to TAVR or at the same time as the index transfemoral TAVR procedure
- Planned PCI of coronary artery lesion(s)
- Planned surgical revascularization of coronary artery lesion(s)
- Non-cardiovascular co-morbidity reducing life expectancy to < 5 years
- Any factor precluding 5-year follow-up
- Prior coronary artery bypass grafting surgery or surgical valve replacement
- Severe mitral regurgitation (> 3+)
- Severe left ventricular dysfunction (LVEF < 30%)
- Low coronary takeoff (high risk for coronary obstruction)
- Acute myocardial infarction within 90 days
- Stroke or transient ischemic attack within 90 days
- Renal insufficiency (eGFR < 30 ml/min) and/or renal replacement Rx
- Hemodynamic or respiratory instability
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Complete Revascularization Percutaneous Coronary Intervention (PCI) Routine PCI (percutaneous coronary intervention) of all suitable coronary artery stenoses of ≥70% in vessels ≥2.5mm in diameter.
- Primary Outcome Measures
Name Time Method Composite of Cardiovascular Death or New Myocardial Infarction or Ischemia-Driven Revascularization or Hospitalization for Unstable Angina or Heart Failure Median follow-up of 3.5 years
- Secondary Outcome Measures
Name Time Method Angina status Median follow-up of 3.5 years As evaluated by the Seattle Angina Questionnaire
Cardiovascular Death Median follow-up of 3.5 years Severe Patient Prosthesis Mismatch (PPM) Reclassification Median follow-up of 3.5 years Proportion of patients with echocardiographic severe PPM immediately post-TAVR, reclassified as non-severe PPM using direct invasive methods.
Cardiovascular Death or New Myocardial Infarction Median follow-up of 3.5 years Deaths will be classified as cardiovascular or non-cardiovascular. All deaths with a clear cardiovascular or unknown cause, will be classified as cardiovascular. However, within cardiovascular deaths, hemorrhagic deaths will be clearly identified. Only deaths due to a documented non-cardiovascular cause (e.g., cancer) will be classified as non-cardiovascular.
Myocardial Infarction will be defined according to the 4th Universal Definition of Myocardial Infarction, with modification for Type 4a (PCI-related) and Type 5 (CABG-related) as defined for the ISCHEMIA trial and as used in the COMPLETE trial.Transaortic Gradient Reclassification Median follow-up of 3.5 years Proportion of patients developing echocardiographic aortic gradient ≥20 mmHg who are found to have a gradient \< 20 mmHg on direct hemodynamic assessment.
Bleeding Median follow-up of 3.5 years Clinically overt, symptomatic bleeding with at least one of the following criteria:
* Fatal, or
* Symptomatic intracranial hemorrhage, or
* Retroperitoneal hemorrhage, or
* Intraocular hemorrhage leading to significant vision loss, or
* Decrease in hemoglobin of 3.0 g/dL (with each blood transfusion unit counting for 1.0 g/dL of Hb) or requiring transfusion of two or more units of red blood cells or equivalent of whole blood.
* Requiring surgical intervention to stop the bleedingEconomic evaluation Median follow-up of 3.5 years Includes health resource utilization, costs, and cost-effectiveness
Transaortic gradient immediately post-TAVR (echocardiographically-derived vs. direct invasive measurement) Immediately post-TAVR VARC-3 Hemodynamic Valve Deterioration Reclassification Median follow-up of 3.5 years Proportion of patients developing ≥ moderate echocardiographic VARC-3 valve deterioration reclassified to \< moderate VARC-3 valve deterioration using direct invasive methods, including mean gradient and valve area.
Composite of CV Death, New MI, IDR or Hospitalization for UA or for HF in patients with PPM and elevated gradients vs those without Median follow-up of 3.5 years Deaths: will be classified as cardiovascular or non-cardiovascular. All deaths with a clear cardiovascular or unknown cause, will be classified as cardiovascular. However, within cardiovascular deaths, hemorrhagic deaths will be clearly identified. Only deaths due to a documented non-cardiovascular cause (e.g., cancer) will be classified as non-cardiovascular.
Myocardial Infarction: will be defined according to the 4th Universal Definition of Myocardial Infarction, with modification for Type 4a (PCI-related) and Type 5 (CABG-related) as defined for the ISCHEMIA trial and as used in the COMPLETE trial.
Hospital admission: for protocol-defined unstable angina, new/worsening NYHA Class IV heart failure, or for protocol-defined Ischemia-driven revascularization, among patients with patient prosthesis mismatch (PPM), elevated echocardiography-derived transaortic gradients and elevated direct invasive transaortic gradient vs those without.Composite outcome of mean echocardiographic gradient ≥ 20mmHg, severe PPM, ≥ moderate AR, thrombosis, endocarditis, and aortic valve re-intervention Median follow-up of 3.5 years Ischemia-Driven Revascularization Median follow-up of 3.5 years Stroke Median follow-up of 3.5 years Defined as the presence of a new focal neurologic deficit thought to be vascular in origin, with signs or symptoms lasting more than 24 hours. It is strongly recommended (but not required) that an imaging procedure such as CT scan or MRI be performed. Stroke will be further classified as ischemic, hemorrhagic or type uncertain.
Patient-reported outcomes Median follow-up of 3.5 years Health-related quality of life as evaluated by the Kansas City Cardiomyopathy Questionnaire at baseline, 30 days, 6 months, 1 year, and annually thereafter.
Contrast-associated acute kidney injury Median follow-up of 3.5 years An absolute rise in serum creatinine of greater than or equal to 44 μmol/L from baseline and/or a relative rise in serum creatinine of ≥25% compared to baseline at any time between 48hrs and 96hrs post-procedure.
New Myocardial Infarction Median follow-up of 3.5 years Hospitalization for Unstable Angina or Heart Failure Median follow-up of 3.5 years Fluoroscopic time for Staged PCI procedure During PCI procedure Total time under fluoroscopy
Contrast Utilization for Stages PCI Procedure During PCI procedure All-cause Mortality Median follow-up of 3.5 years Includes deaths from both cardiac and non-cardiac causes
Trial Locations
- Locations (72)
Piedmont
🇺🇸Atlanta, Georgia, United States
Prairie Vascular
🇨🇦Regina, Saskatchewan, Canada
JFK Medical Center
🇺🇸Atlantis, Florida, United States
Centre for Cardiovascular Innovation-Centre d'Innovation Cardiovasculaire (CCI-CIC)
🇨🇦Vancouver, British Columbia, Canada
Methodist Le Bonheur Healthcare
🇺🇸Germantown, Tennessee, United States
Royal Columbian Hospital
🇨🇦New Westminster, British Columbia, Canada
NYU Langone Hospital - Long Island
🇺🇸Mineola, New York, United States
Dartmouth Hitchcock Medical Center
🇺🇸Lebanon, New Hampshire, United States
University of Minnesota Medical Center
🇺🇸Minneapolis, Minnesota, United States
Missouri Baptist
🇺🇸Saint Louis, Missouri, United States
William Beaumont Hospital
🇺🇸Royal Oak, Michigan, United States
Our Lady of Lourdes
🇺🇸Camden, New Jersey, United States
St. Alphonsus Regional Medical Center
🇺🇸Boise, Idaho, United States
Torrance Memorial Medical Center
🇺🇸Torrance, California, United States
University at Buffalo
🇺🇸Buffalo, New York, United States
Santa Barbara Cottage Hospital
🇺🇸Santa Barbara, California, United States
Veteran Affairs Palo Alto Health Care System
🇺🇸Palo Alto, California, United States
Valley Hospital
🇺🇸Ridgewood, New Jersey, United States
Ascension St. Mary's
🇺🇸Saginaw, Michigan, United States
Baptist Health Jacksonville
🇺🇸Jacksonville, Florida, United States
Miami Cardiac and Vascular/Baptist Hospital
🇺🇸Miami, Florida, United States
Huntsville Heart Center
🇺🇸Huntsville, Alabama, United States
Bryan Heart
🇺🇸Lincoln, Nebraska, United States
Northeast Georgia Health System
🇺🇸Gainesville, Georgia, United States
St. Louis University
🇺🇸Saint Louis, Missouri, United States
Hamilton Health Sciences
🇨🇦Hamilton, Ontario, Canada
Mount Sinai
🇺🇸New York, New York, United States
Parkwest Medical Center
🇺🇸Knoxville, Tennessee, United States
Bellin Health System
🇺🇸Green Bay, Wisconsin, United States
Kaiser Permanente Northwest
🇺🇸Clackamas, Oregon, United States
Mount Carmel
🇺🇸Columbus, Ohio, United States
Ottawa Heart
🇨🇦Ottawa, Ontario, Canada
Vancouver General Hospital
🇨🇦Vancouver, British Columbia, Canada
New Brunswick Heart
🇨🇦Saint John, New Brunswick, Canada
Sunnybrook Hospital
🇨🇦Toronto, Ontario, Canada
St. Michael's Hospital
🇨🇦Toronto, Ontario, Canada
Saint Boniface
🇨🇦Winnipeg, Manitoba, Canada
CIUSSS de l'Estrie-CHUS
🇨🇦Sherbrooke, Quebec, Canada
Montréal Heart
🇨🇦Montréal, Quebec, Canada
Sacré-Coeur
🇨🇦Montréal, Quebec, Canada
Arizona Cardiovascular Research
🇺🇸Phoenix, Arizona, United States
Oklahoma Heart
🇺🇸Oklahoma City, Oklahoma, United States
Ascension Columbia St. Mary's
🇺🇸Milwaukee, Wisconsin, United States
Loma Linda University
🇺🇸Redlands, California, United States
Midwest Cardiovascular Research and Education Foundation
🇺🇸Elkhart, Indiana, United States
Parkview Research Center
🇺🇸Fort Wayne, Indiana, United States
Cardiovascular Research Institute of Kansas
🇺🇸Wichita, Kansas, United States
Ascension Alexian Brothers
🇺🇸Chicago, Illinois, United States
Tufts Medical
🇺🇸Boston, Massachusetts, United States
Midwest Heart and Vascular
🇺🇸Overland Park, Kansas, United States
Sparrow Clinical Research Institute
🇺🇸Lansing, Michigan, United States
Massachusetts General Hospital
🇺🇸Boston, Massachusetts, United States
St. Joseph Mercy Health System
🇺🇸Ypsilanti, Michigan, United States
Boone Hospital
🇺🇸Columbia, Missouri, United States
CentraCare Heart and Vascular Center
🇺🇸Saint Cloud, Minnesota, United States
Columbia University Medical Center
🇺🇸New York, New York, United States
St. Joseph's Hospital
🇺🇸Syracuse, New York, United States
Novant Health Heart and Vascular Institute
🇺🇸Charlotte, North Carolina, United States
Summa Health System
🇺🇸Akron, Ohio, United States
Ballad Health CVA Heart Institute
🇺🇸Kingsport, Tennessee, United States
Cardiovascular Surgery Clinic/Baptist Memorial
🇺🇸Memphis, Tennessee, United States
Baylor Scott & White Plano
🇺🇸Plano, Texas, United States
Baylor Scott & White Round Rock
🇺🇸Round Rock, Texas, United States
HCA Houston Healthcare Medical Center
🇺🇸Houston, Texas, United States
University of Vermont Medical Center
🇺🇸Burlington, Vermont, United States
Centre Hospitalier de l'Université de Montréal
🇨🇦Montréal, Quebec, Canada
University of Alberta, Mazankowski Heart Institute
🇨🇦Edmonton, Alberta, Canada
St. Paul's Hospital
🇨🇦Vancouver, British Columbia, Canada
Montefiore Medical Center
🇺🇸Bronx, New York, United States
University of Kansas Medical Center
🇺🇸Kansas City, Kansas, United States
Rhode Island Hospital
🇺🇸Providence, Rhode Island, United States
Queen Elizabeth II Health Sciences Centre
🇨🇦Halifax, Nova Scotia, Canada