Coronary Artery Disease in Aortic Stenosis: CABG + SAVR vs. TAVR + PCI: Data from Spanish Centers

Multiple randomized studies have shown comparable or superior efficacy of transcatheter aortic valve replacement (TAVR) vs. coronary artery bypass graft (CABG).  However, many of these studies excluded patients requiring myocardial revascularization, despite coronary artery disease (CAD) being highly prevalent among degenerative aortic stenosis patients.  

The current guidelines suggest combining CABG and SAVR. When it comes to percutaneous coronary intervention (PCI), available evidence is less conclusive. However, in the daily practice, PCI is commonly performed before, during or after TAVR. 

Study Objective: Comparing TAVR vs CABG in AS Patients with CAD

The aim of this study was to look at clinical events at 12 months in patients with AS and significant CAD undergoing TAVR + PCI or CABG + SAVR. Amat-Santos et al. Carried out a retrospective analysis of a multicenter study involving 14 tertiary centers in Spain. Coronary complexity was classified into 5 categories: 1,2, or 3 vessel compromise, isolated left main (LM) or LM with multivessel disease. It excluded patients with hybrid treatments, other concomitant therapies, or poor surgical candidates. Decisions were made by the local Heart Team.

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The primary outcome was a composite of all-cause mortality and stroke at one-year follow-up. Secondary outcomes included the individual primary end point components, acute myocardial infarction (AMI) unrelated to the procedure, need for new revascularization or valve re-intervention, aortic failure, renal lesion, or pacemaker implantation. 

Clinical outcomes of TAVR + PCI vs. CABG + SAVR at one year

1342 patients were looked at, 46.6% undergoing TAVR + PCI and 53.1% CABG + SAVR. Transcatheter patients were older (81.6±5.8 vs 72.1±7 years; P < 0.001) and mostly women (43.3% vs 23.8%; P < 0.001). Extensive CAD was more common among surgery patients (3 vessels: 19.2% vs 11.8%; P < 0.001; LM: 14.5% vs 8%; P < 0.001). 42.7% of TAVR patients received balloon expendable valves, while 74.2% of SAVR patients received ≤23 mm valves vs. 23.3% of TAVR patients (P < 0.001). Complete revascularization was achieved in 83.4% of the percutaneous group (50.9% before, 16.3% concomitant and 32.8% after) and in 89.6% of surgery patients.

Mortality primary end point and stroke was higher among surgery patients (10.6% vs 3.1%; P = 0.002). Need for pacemaker implantation was higher among percutaneous patients (15% vs 6.5%, P < 0.001), as was residual AS incidence (moderate to severe) in TAVR patients (11.5% vs 1.3%).

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At one-year follow-up, there were no significant differences in AMI incidence or need for revascularization. Among TAVR patients, there was higher primary end point rate in patients receiving PCI before TAVR (though this finding was not stratified).

Conclusions

Despite TAVR patients presented higher baseline risk when choosing the transcatheter approach, the combined end point of mortality and stroke resulted higher in patients undergoing surgery.

Título Original: Surgical vs Transcatheter Treatment in Patients With Coronary Artery Disease and Severe Aortic Stenosis.

Referencia: Amat-Santos, I, García-Gómez, M, Avanzas, P. et al. Surgical vs Transcatheter Treatment in Patients With Coronary Artery Disease and Severe Aortic Stenosis. J Am Coll Cardiol Intv. 2024 Nov, 17 (21) 2472–2485. https://doi.org/10.1016/j.jcin.2024.09.003.