Staged Complete Revascularization for Coronary Artery Disease vs Medical Management Alone in Patients With AS Undergoing Transcatheter Aortic Valve Replacement

Study Overview
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Brief Summary
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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.

Official Title
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A Randomized, Comparative Effectiveness Study of Staged Complete Revascularization With Percutaneous Coronary Intervention to Treat Coronary Artery Disease vs Medical Management Alone in Patients With Symptomatic Aortic Valve Stenosis Undergoing Elective Transfemoral Transcatheter Aortic Valve Replacement: The COMPLETE TAVR Study

Conditions
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Aortic Stenosis, Coronary Artery Disease, Coronary Stenosis

Intervention / Treatment
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* Procedure: Percutaneous Coronary Intervention (PCI)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: - 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. Exclusion Criteria: 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
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Complete Revascularization<br>Routine PCI (percutaneous coronary intervention) of all suitable coronary artery stenoses of ≥70% in vessels ≥2.5mm in diameter. | Procedure: Percutaneous Coronary Intervention (PCI)<br>* PCI of all qualifying lesions.<br>|
| No Intervention: Medical Therapy Alone<br>No revascularization of coronary artery lesions. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 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

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Cardiovascular Death or New Myocardial Infarction | 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. | Median follow-up of 3.5 years | 
| Transaortic gradient immediately post-TAVR (echocardiographically-derived vs. direct invasive measurement) |  | Immediately post-TAVR | 
| Transaortic Gradient Reclassification | Proportion of patients developing echocardiographic aortic gradient ≥20 mmHg who are found to have a gradient < 20 mmHg on direct hemodynamic assessment. | Median follow-up of 3.5 years | 
| VARC-3 Hemodynamic Valve Deterioration Reclassification | 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. | Median follow-up of 3.5 years | 
| Severe Patient Prosthesis Mismatch (PPM) Reclassification | Proportion of patients with echocardiographic severe PPM immediately post-TAVR, reclassified as non-severe PPM using direct invasive methods. | Median follow-up of 3.5 years | 
| Composite of CV Death, New MI, IDR or Hospitalization for UA or for HF in patients with PPM and elevated gradients vs those without | 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. | Median follow-up of 3.5 years | 
| 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 | 
| Cardiovascular Death |  | Median follow-up of 3.5 years | 
| New Myocardial Infarction |  | Median follow-up of 3.5 years | 
| Ischemia-Driven Revascularization |  | Median follow-up of 3.5 years | 
| Hospitalization for Unstable Angina or Heart Failure |  | Median follow-up of 3.5 years | 
| All-cause Mortality | Includes deaths from both cardiac and non-cardiac causes | Median follow-up of 3.5 years | 
| Stroke | 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. | Median follow-up of 3.5 years | 
| Bleeding | 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 bleeding | Median follow-up of 3.5 years | 
| Angina status | As evaluated by the Seattle Angina Questionnaire | Median follow-up of 3.5 years | 
| Economic evaluation | Includes health resource utilization, costs, and cost-effectiveness | Median follow-up of 3.5 years | 
| Patient-reported outcomes | Health-related quality of life as evaluated by the Kansas City Cardiomyopathy Questionnaire at baseline, 30 days, 6 months, 1 year, and annually thereafter. | Median follow-up of 3.5 years | 
| Contrast-associated acute kidney injury | 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. | Median follow-up of 3.5 years | 
| Fluoroscopic time for Staged PCI procedure | Total time under fluoroscopy | During PCI procedure | 
| Contrast Utilization for Stages PCI Procedure |  | During PCI procedure | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Transcatheter Aortic Valve Replacement, Percutaneous Coronary Intervention, Coronary Artery Disease, Aortic Stenosis