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Published on: March 26, 2018
Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Complex Coronary Artery Disease
Alberto Alperi1, Siamak Mohammadi1, Francisco Campelo-Parada2
1Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
Insights
Transcatheter aortic valve replacement (TAVR) plus percutaneous coronary intervention (PCI) showed similar major adverse cardiac and cerebrovascular events compared to surgical aortic valve replacement (SAVR) plus coronary artery bypass grafting (CABG). However, TAVR + PCI patients had a higher need for repeat coronary revascularization.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Complex coronary artery disease (CAD) patients were excluded from major TAVR vs. SAVR trials.
- Limited data exist comparing TAVR + PCI with SAVR + CABG in this population.
Purpose of the Study:
- To compare clinical outcomes of TAVR + PCI versus SAVR + CABG in patients with severe aortic stenosis (AS) and complex CAD.
- To evaluate major adverse cardiac and cerebrovascular events (MACCE) between the two treatment strategies.
Main Methods:
- A multicenter study included patients with severe AS and complex CAD (SYNTAX score >22 or unprotected left main disease).
- A 1:1 propensity-matched analysis compared outcomes between TAVR + PCI and SAVR + CABG groups.
- MACCE, including mortality, myocardial infarction, stroke, and need for revascularization, were assessed.
Main Results:
- After propensity matching, 156 pairs of patients were analyzed with a median follow-up of 3 years.
- No significant differences were found in MACCE, all-cause mortality, myocardial infarction, or stroke between the TAVR + PCI and SAVR + CABG groups.
- The TAVR + PCI group demonstrated a significantly higher rate of new coronary revascularization.
Conclusions:
- TAVR + PCI and SAVR + CABG offer similar MACCE rates in severe AS and complex CAD patients at 3-year follow-up.
- TAVR + PCI is associated with an increased risk of repeat coronary revascularization.
- Further clinical trials are necessary to confirm these findings.
Objectives:
The aim of this study was to compare, in a cohort of patients with complex coronary artery disease (CAD) and severe aortic stenosis (AS), the clinical outcomes associated with transfemoral transcatheter aortic valve replacement (TAVR) (plus percutaneous coronary intervention [PCI]) versus surgical aortic valve replacement (SAVR) (plus coronary artery bypass grafting [CABG]).
Background:
Patients with complex CAD were excluded from the main randomized trials comparing TAVR with SAVR, and no data exist comparing TAVR + PCI vs SAVR + CABG in such patients.
Methods:
A multicenter study was conducted including consecutive patients with severe AS and complex CAD (SYNTAX [Synergy Between PCI with Taxus and Cardiac Surgery] score >22 or unprotected left main disease). A 1:1 propensity-matched analysis was performed to account for unbalanced covariates. The rates of major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, nonprocedural myocardial infarction, need for new coronary revascularization, and stroke, were evaluated.
Results:
A total of 800 patients (598 undergoing SAVR + CABG and 202 undergoing transfemoral TAVR + PCI) were included, and after propensity matching, a total of 156 pairs of patients were generated. After a median follow-up period of 3 years (interquartile range: 1-6 years), there were no significant differences between groups for MACCE (HR for transfemoral TAVR vs SAVR: 1.33; 95% CI: 0.89-1.98), all-cause mortality (HR: 1.25; 95% CI: 0.81-1.94), myocardial infarction (HR: 1.16; 95% CI: 0.41-3.27), and stroke (HR: 0.42; 95% CI: 0.13-1.32), but there was a higher rate of new coronary revascularization in the TAVR + PCI group (HR: 5.38; 95% CI: 1.73-16.7).
Conclusions:
In patients with severe AS and complex CAD, TAVR + PCI and SAVR + CABG were associated with similar rates of MACCE after a median follow-up period of 3 years, but TAVR + PCI recipients exhibited a higher risk for repeat coronary revascularization. Future trials are warranted.
