Coronary Hemodynamics in Patients With Severe Aortic Stenosis and Coronary Artery Disease Undergoing Transcatheter Aortic Valve Replacement: Implications for Clinical Indices of Coronary Stenosis Severity

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OBJECTIVES: In this study, a systematic analysis was conducted of phasic intracoronary pressure and flow velocity in patients with severe aortic stenosis (AS) and coronary artery disease, undergoing transcatheter aortic valve replacement (TAVR), to determine how AS affects: 1) phasic coronary flow; 2) hyperemic coronary flow; and 3) the most common clinically used indices of coronary stenosis severity, instantaneous wave-free ratio and fractional flow reserve.

BACKGROUND: A significant proportion of patients with severe aortic stenosis (AS) have concomitant coronary artery disease. The effect of the valve on coronary pressure, flow, and the established invasive clinical indices of stenosis severity have not been studied.

METHODS: Twenty-eight patients (30 lesions, 50.0% men, mean age 82.1 ± 6.5 years) with severe AS and coronary artery disease were included. Intracoronary pressure and flow assessments were performed at rest and during hyperemia immediately before and after TAVR.

RESULTS: Flow during the wave-free period of diastole did not change post-TAVR (29.78 ± 14.9 cm/s vs. 30.81 ± 19.6 cm/s; p = 0.64). Whole-cycle hyperemic flow increased significantly post-TAVR (33.44 ± 13.4 cm/s pre-TAVR vs. 40.33 ± 17.4 cm/s post-TAVR; p = 0.006); this was secondary to significant increases in systolic hyperemic flow post-TAVR (27.67 ± 12.1 cm/s pre-TAVR vs. 34.15 ± 17.5 cm/s post-TAVR; p = 0.02). Instantaneous wave-free ratio values did not change post-TAVR (0.88 ± 0.09 pre-TAVR vs. 0.88 ± 0.09 post-TAVR; p = 0.73), whereas fractional flow reserve decreased significantly post-TAVR (0.87 ± 0.08 pre-TAVR vs. 0.85 ± 0.09 post-TAVR; p = 0.001).

CONCLUSIONS: Systolic and hyperemic coronary flow increased significantly post-TAVR; consequently, hyperemic indices that include systole underestimated coronary stenosis severity in patients with severe AS. Flow during the wave-free period of diastole did not change post-TAVR, suggesting that indices calculated during this period are not vulnerable to the confounding effect of the stenotic aortic valve.


  • Yousif Ahmad
  • Matthias Götberg
  • Christopher Cook
  • James P. Howard
  • Iqbal Malik
  • Ghada Mikhail
  • Angela Frame
  • Ricardo Petraco
  • Christopher Rajkumar
  • Ozan Demir
  • Juan F. Iglesias
  • Ravinay Bhindi
  • Sasha Koul
  • Nearchos Hadjiloizou
  • Robert Gerber
  • Punit Ramrakha
  • Neil Ruparelia
  • Nilesh Sutaria
  • Gajen Kanaganayagam
  • Ben Ariff
  • And 8 others
  • Michael Fertleman
  • Jon Anderson
  • Andrew Chukwuemeka
  • Darrel Francis
  • Jamil Mayet
  • Patrick Serruys
  • Justin Davies
  • Sayan Sen
External organisations
  • Hammersmith Hospital
  • Imperial College Healthcare NHS Trust
  • Lausanne University Hospital
  • Royal North Shore Hospital
  • Conquest Hospital
  • Imperial College London
  • Skåne University Hospital
Research areas and keywords

Subject classification (UKÄ) – MANDATORY

  • Cardiac and Cardiovascular Systems


  • aortic stenosis, coronary flow, fractional flow reserve, instantaneous wave-free ratio, TAVR
Original languageEnglish
Pages (from-to)2019-2031
Number of pages13
JournalJACC. Cardiovascular interventions
Issue number20
Publication statusPublished - 2018
Publication categoryResearch