Transcatheter aortic valve replacement and percutaneous coronary intervention versus surgical aortic valve replacement and coronary artery bypass grafting in patients with severe aortic stenosis and concomitant coronary artery disease: A systematic review and meta‐analysis

Abstract

Objectives We performed a systematic review and meta‐analysis to evaluate the early and midterm outcomes of patients who underwent surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) against patients who had transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI). Background Contemporary guidelines suggest that surgical or percutaneous revascularization of significant coronary artery disease (CAD) in patients with severe aortic stenosis (AS) is a reasonable strategy. Methods We conducted a comprehensive search of Medline and Embase to identify studies comparing a percutaneous transcatheter versus a surgical approach. Random effects meta‐analyses using the Mantel–Haenszel method were performed to estimate the effect of percutaneous compared surgical strategies using aggregate data. Results Six studies reporting on 1770 participants were included in the meta‐analysis. There were no significant differences in effect estimates for early and midterm mortality (OR: 0.78; 95% CI, 0.50–1.20 and OR: 1.09; 95% CI, 0.80–1.49, respectively) or myocardial infarction (OR: 0.52; 95% CI, 0.20–1.33 and OR: 1.34; 95% CI, 0.67–2.65, respectively). No significant difference was shown for peri‐procedural stroke (OR: 0.80; 95% CI, 0.35–1.87). A transcatheter approach had a higher rate of major vascular complications (OR: 14.44; 95% CI, 4.42–47.16), but a lower rate of acute kidney injury (OR: 0.41; 95% CI, 0.19–0.91). Conclusion Our analysis suggests that a percutaneous transcatheter approach confers similar outcomes compared to a surgical approach in patients with severe AS and CAD. However, our findings are based on low quality studies and should serve as hypothesis generating. In the absence of adequately powered studies yielding high level evidence, individualized decision making should be based on surgical risk assessment.

Surgical versus Interventional Treatment of Concomitant Aortic Valve Stenosis and Coronary Artery Disease

“…Similar distribution of demographics and risk profiles for surgically or interventionally treated patients with AS and CAD was reported in numerous studies. 16,17,19 A prior cardiac surgery per se is not a contraindication to surgical treatment and was not considered as an exclusion criterion in our analysis. Nevertheless, those patients were more likely to undergo TAVI in consensus of the heart team due to the considerably higher operative risk.…”

“…Patients who underwent CABG+AVR stayed longer in-hospital with a mean of 14.4 (11)(12)(13)(14)(15)(16)(17) vs. 9.4 (5-23) days after PCI+TAVI; (P<0.001). However, the last refers to the length of stay for TAVI without adding that for the corresponding previously performed PCI.…”

“…2 Furthermore, a recent meta-analysis showed an advantage in favor of PCI+TAVI regarding the 30-day mortality incidence with 5.2% vs. 7.5% after combined surgical approach, without statistical significance. 16 Nonetheless, the initial advantage of PCI+TAVI group equaled out in the 2-…”

Aortic Valve Disease and Associated Complex CAD: The Interventional Approach

“…Moreover, it is reasonable to combine the two procedures (coronary revascularization and valve replacement) whenever a major cardiac operation is planned in light of the risks related with a future redo operation. A recent meta-analysis by Kotronias et al showed that a percutaneous transcatheter approach combing TAVI and PCI conferred similar outcomes to a surgical approach combining SAVR and CABG [54]. Therefore, patients with severe AS and CAD can have either approach determined predominantly by the surgical risk.…”

Aortic valve replacement plus revascularization: The battle of surgical versus transcatheter approach still rages

“…In this issue of Catheterization and Cardiovascular Interventions , Kotronias et al (3) performed a (non‐patient‐level) systematic review and meta‐analysis to evaluate the early and mid‐term outcomes (at 2 years) of patients who underwent a totally percutaneous transcatheter approach (TAVR plus percutaneous coronary intervention ‐ PCI) against patients who had a complete surgical approach (SAVR plus CABG). A total of 6 studies were included, evaluating 1770 participants of which 631 had TAVR and PCI and 1,139 had SAVR and CABG.…”