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Surgical vs. Transcatheter Treatment in Patients With CAD and AS
Quick Takes
- Findings from this retrospective, propensity-matched analysis compared 1-year clinical outcomes for CABG + SVR vs. TAVR + PCI among patients with severe AS and CAD.
- Patients undergoing TAVR + PCI were older and more likely to be female.
- TAVR + PCI group was more likely to receive a permanent pacemaker and have moderate to severe AR.
- Despite higher clinical baseline risk, mortality and stroke events were significantly lower in the TAVR + PCI group (8.8% vs. 4.5%, p = 0.002).
Study Questions:
What are clinical outcomes among patients with severe aortic stenosis (AS) and coronary artery disease (CAD) undergoing surgical aortic valve replacement (SAVR) plus revascularization versus transcatheter aortic valve replacement (TAVR) plus percutaneous coronary intervention (PCI)?
Methods:
This national, multicenter, retrospective study in Spain involved patients with severe AS and CAD treated between 2018 and 2021. Patients underwent either PCI + TAVR or coronary artery bypass grafting (CABG) + SAVR and were compared. The primary endpoint was all-cause mortality and stroke at 1 year. Propensity-score analysis was performed to mitigate baseline differences.
Results:
Of the 1,342 included patients, 625 (46.6%) underwent PCI + TAVR and 713 (53.1%) underwent CABG + SAVR. Patients in the percutaneous arm were older (81.6 ± 5.8 vs. 72.1 ± 7, p < 0.001), had a higher prevalence of chronic kidney disease (40.6% vs. 14.9%, p < 0.001), and higher Society of Thoracic Surgeons (STS) risk score (4.3% [2.8-6.4] vs. 2.2% [1.4-3.3], p < 0.001). Technical success rates were 96% for PCI + TAVR and 98.4% for CABG + SAVR (p = 0.008), with similar periprocedural mortality (0.8 vs. 0.7%, p = 0.999). However, the mortality + stroke rate at 30 days was higher in the CABG + SAVR group compared to PCI + TAVR, both in the unmatched (12.2% vs. 4.7%, p = 0.005) and matched cohorts (8.8% vs. 4.5%, p = 0.002), persisting at 1-year follow-up.
Conclusions:
Despite lower baseline risk, CABG + SAVR in patients with severe AS and CAD was associated with a higher rate of death and stroke compared to PCI + TAVR, highlighting the necessity for a large, randomized analysis.
Perspective:
Findings from this retrospective, registry, propensity-matched analysis compared 1-year clinical outcomes for CABG + SVR vs. TAVR + PCI among patients with severe AS and CAD. Patients undergoing TAVR + PCI were older and more likely to be female. TAVR + PCI group was more likely to receive a permanent pacemaker and have moderate to severe AR. Despite higher clinical baseline risk, mortality and stroke events were significantly lower in the TAVR + PCI group (8.8% vs. 4.5%, p = 0.002). Previous findings evaluating a treatment approach for AS plus CAD have shown inconsistent results. Findings from this study are limited by the trial design and will need validation by a randomized controlled trial.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Structural Heart Disease
Keywords: Aortic Valve Stenosis, Coronary Artery Bypass, Coronary Artery Disease, Percutaneous Coronary Intervention, Transcatheter Aortic Valve Replacement
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