Optimal Management for Moderate Aortic Stenosis at Time of Coronary Artery Bypass Grafting

Established guidelines recommend consideration of concomitant surgical aortic valve replacement (SAVR) at the time of coronary artery bypass grafting (CABG) in patients with moderate aortic stenosis (AS) to avoid future reoperation for AS progression. The advent of transcatheter aortic valve replacement allows treatment of AS without mediastinal entry. This questions the optimal treatment choice of moderate AS in patients undergoing CABG. We compared outcomes of CABG with or without SAVR in patients with moderate AS.

Patients ≥65 years old with moderate AS who underwent CABG or CABG+SAVR from 2011 to 2022 were identified from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Exclusions included cardiogenic shock, endocarditis, severe aortic insufficiency, and non-sternotomy cases. Analyzed outcomes included perioperative complications, midterm mortality, and readmission for heart failure or aortic valve (AV) intervention.

Of 18,247 patients, 9325 (51.1%) underwent CABG+SAVR and 8922 (48.9%) underwent isolated CABG. The isolated CABG cohort had lower operative mortality and postoperative complications. Risk-adjusted midterm outcomes showed similar all-cause mortality. Patients who underwent isolated CABG were at an increased risk for midterm readmission for heart failure and AV intervention. Rate of AV intervention at 8 years for isolated CABG patients compared with CABG+SAVR was 25.9% vs 2.4%, respectively.

Deferring SAVR during CABG in patients with moderate AS may lower operative risk without affecting midterm mortality but increases heart failure readmissions and later AV interventions. Further studies are needed to determine whether delaying the AV intervention translates to reduced prosthetic valve degeneration without increasing long-term morbidity and mortality.