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Transcatheter Aortic Valve Replacement: The New Standard in Patients With Previous Coronary Bypass Grafting?
Jochen Reinöhl1, Klaus Kaier2, Holger Reinecke3
1Department of Cardiology and Angiology I, Heart Center Freiburg University, Freiburg, Germany.
Insights
Transcatheter aortic valve replacement (TAVR) is increasingly preferred over surgical aortic valve replacement for patients with prior coronary artery bypass grafting (CABG). TAVR shows favorable outcomes and resource utilization compared to redo surgery in this high-risk group.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- A significant number of patients undergoing aortic valve replacement have a history of coronary artery bypass grafting (CABG).
- Redo surgery in these patients poses increased operative risks.
- Transcatheter aortic valve replacement (TAVR) emerged as an alternative treatment option.
Purpose of the Study:
- To evaluate the impact of TAVR introduction on clinical practice and outcomes.
- To compare TAVR with surgical aortic valve replacement in patients with and without prior CABG.
- To analyze trends in treatment selection and in-hospital results.
Main Methods:
- Analysis of in-hospital outcome data from Germany (2007-2013).
- Inclusion of patients undergoing isolated surgical aortic valve replacement or TAVR.
- Stratification of patients based on the presence or absence of prior CABG.
Main Results:
- TAVR adoption significantly increased in patients with prior CABG, while surgical aortic valve replacement decreased.
- In 2013, TAVR was the dominant therapy (nearly 90%) for patients with prior CABG.
- In-hospital mortality was higher in patients with prior CABG for both TAVR and surgical aortic valve replacement.
- TAVR demonstrated lower rates of stroke and bleeding compared to redo surgical aortic valve replacement.
- Resource utilization, indicated by discharge destination, favored TAVR in patients with prior CABG.
Conclusions:
- TAVR has become the preferred treatment for patients with prior CABG since its introduction in 2007.
- In-hospital outcome data support the shift from redo surgical aortic valve replacement to TAVR in this patient population.
Objectives:
The aim of this study was to assess how the introduction of transcatheter aortic valve replacement (TAVR) has changed clinical practice and outcome in patients who have previously undergone coronary artery bypass grafting (CABG).
Background:
A significant proportion of patients admitted for aortic valve replacement have previously undergone CABG and are therefore at increased operative risk in case of redo surgery.
Methods:
In-hospital outcome data were analyzed from patients with or without previous CABG undergoing isolated surgical aortic valve replacement or TAVR in Germany from 2007 to 2013.
Results:
In total, 32,581 TAVR and 55,992 surgical aortic valve replacement procedures were performed in patients with (n = 6,221) or without (n = 82,352) previous CABG. TAVR increased markedly in patients with previous CABG, from 18 procedures in 2007 to 1,191 in 2013, while surgical aortic valve replacement decreased in these patients from 471 to 179 procedures. In 2013, TAVR was the preferred therapy in almost 90% of patients with previous CABG. In-hospital mortality was increased in patients with previous CABG compared with those without (7.6% vs. 6.3% for TAVR and 7.2% vs. 2.6% for surgical aortic valve replacement). Bleeding and stroke rates were also increased with redo surgical aortic valve replacement procedures (with vs. without previous CABG: stroke, 3.2% vs. 1.8%; relevant bleeding, 29.6% vs. 13.4%; acute kidney injury, 4.2% vs. 2.9%), whereas this was not the case with TAVR (stroke, 2.1% vs. 2.6%; relevant bleeding, 7.3% vs. 8.3%; acute kidney injury, 6.3% vs. 5.4% respectively). A similar influence was seen in resource utilization (discharge destination home: TAVR after CABG, 51%; surgical aortic valve replacement after CABG, 31%).
Conclusions:
Since its introduction in 2007, TAVR has been increasingly used in Germany in patients with previous CABG, and in-hospital outcome data support the trend away from redo surgery.
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