TAVR with Prior MRS: A New Challenge

The benefits of transcatheter aortic valve replacement (TAVR) for high-risk, prohibitive-risk (class I) or intermediate-risk (class IIa) patients have already been proven, but there is a growing population of patients with a history of myocardial revascularization surgery (MRS) who experience severe aortic stenosis. Decision-making in these cases is anything but simple, mainly due to the presence of coronary artery grafts and the fact that there is a prior surgery. Particularly, internal thoracic artery grafts in the anterior descending artery are too close to the sternum, thus entailing higher morbidity and mortality.

The information currently available is scarce and the best conduct for this patient group remains unknown.

This study analyzed 15,055 patients who, between 2012 and 2014, experienced severe aortic stenosis and had a history of MRS. Among them, 8885 (59%) underwent TAVR and 6170 (41%) underwent surgical aortic valve replacement (SAVR). The number of TAVRs increased over time.

Compared with patients who underwent SAVR, patients in the TAVR group were older (80.7 vs. 73.6 years old; p < 0.001) and most of them were female (25.8% vs. 18.6%; p < 0.0001). This last group also presented higher rates of hypertension, angioplasty, heart failure, peripheral vascular disease, permanent pacemaker implantation, cardioverter defibrillator implantation, chronic renal insufficiency, anemia, chronic obstructive pulmonary disease (COPD), hypothyroidism, cancer, and liver disease. In turn, among the SAVR group, there were more smokers and patients presented higher rates of atrial fibrillation, obesity, and bleeding disorders.

Read also: Bicuspid Valves Do Not Increase Mortality in TAVR.

Propensity score matching resulted in 3880 equal pairs.

After making the sample more uniform, in-hospital progress was similar (2.3% for TAVR vs. 2.4% for SAVR), but the TAVR group presented lower incidence of acute myocardial infarction (1.5% vs. 3.4%; p < 0.001), stroke (1.4% vs. 2.7%; p < 0.001), bleeding (10.6% vs. 24.6%; p < 0.001), and acute kidney injury (16.2% vs. 19.3%; p < 0.001). Patients in the TAVR group experienced a higher need for definitive pacemaker implantation, but there were no differences as regards the need for dialysis or the incidence of vascular complications.

Read also: Significant Association Between Suprarenal Fixation of Endoprostheses and Renal Dysfunction.

The rates of in-hospital stay were higher among the SAVR group.

Conclusion 

TAVR is being increasingly used as the preferred modality for aortic valve replacement in patients with prior MRS. Compared with SAVR, TAVR is associated with similar mortality but lower rates of in-hospital complications in this important subset of patients.

Editorial Comment

Severe aortic stenosis requiring intervention is present in about 10% of all patients with prior MRS, thus constituting a great challenge as regards the choice of treatment strategy.

While there is no follow-up to this analysis and there were no differences among groups as regards in-hospital mortality, this study shows that TAVR is feasible and safe, and it also offers lower rates of severe complications that might compromise social and individual patient progress (such as stroke). Additionally, the length of hospital stay for these patients is lower, surely generating lower costs for the healthcare system.

Courtesy of Dr. Carlos Fava.

Original title: Transcatheter Versus Surgical Aortic Valve Replacement in Patients with Prior Coronary Artery Bypass Grafting: Trends in Utilization and a Propensity-Score Matched Analysis of In-hospital Outcomes.

Reference: Tanush Gupta et al. Circ Cardiovasc Interv 2018;11:e006179.

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