Transcatheter aortic valve replacement- management of patients with significant coronary artery disease undergoing aortic valve interventions: surgical compared to catheter-based approaches in hybrid procedures

Abstract

Background Coronary artery disease (CAD) is associated with poorer outcomes after aortic valve replacement (AVR). For high-risk patients with complex CAD, combined transcatheter aortic valve replacement (TAVR) plus off-pump/minimally-invasive coronary artery bypass (OPCAB/MIDCAB) has been proposed. Methods A prospective registry analysis was performed to compare the characteristics and outcomes of patients undergoing TAVR+OP/MIDCAB with those undergoing TAVR plus percutaneous coronary intervention (PCI) and surgical AVR plus coronary artery bypass grafting (CABG) between 2008 and 2015 at a single site in Germany. Results 464 patients underwent SAVR+CABG, 50 underwent TAVR+OP/MIDCAB, and 112 underwent TAVR+PCI. The mean ages ( p < 0.001) and logistic EuroSCOREs (p < 0.001) were similarly higher in TAVR+OP/MIDCAB and TAVR+PCI patients compared to SAVR+CABG patients. Prior cardiac surgery was more common in TAVR+PCI than in TAVR+OP/MIDCAB and SAVR+CABG patients (p < 0.001). Procedural times were shortest (p < 0.001), creatine kinase (muscle brain) levels least elevated (p < 0.001), pericardial tamponade least common ( p = 0.027), and length of hospital stay shortest ( p = 0.011) in TAVR+PCI, followed by TAVR+OP/MIDCAB and SAVR+CABG patients. In-hospital mortality was highest for TAVR+OP/MIDCAB patients (18.0%) with comparable rates for TAVR+PCI and SAVR+CABG groups (9.0 and 6.9%; p = 0.009). Mortality by 12 months was more probable after TAVR+OP/MIDCAB (HR: 2.17, p = 0.002) and TAVR/PCI (HR: 1.63, p = 0.010) than after SAVR+CABG, with the same true of rehospitalisation (HR: 2.39, p = 0.003 and HR: 1.63, p = 0.033). Conclusions TAVR+OP/MIDCAB patients share many characteristics with TAVR+PCI patients, with only slightly poorer long-term outcomes. In patients ineligible for SAVR+CABG and TAVR+PCI, hybrid interventions are reasonable second-line options. Electronic supplementary material The online version of this article (10.1186/s12872-019-1087-2) contains supplementary material, which is available to authorized users.

Coronary revascularization during treatment of severe aortic stenosis: A meta‐analysis of the complete percutaneous approach (PCI plus TAVR) versus the complete surgical approach (CABG plus SAVR)

“…In Italian OBSERVANT study, after propensity score matching, mean Euroscore II in both cohorts was 7,8% 15 . In the third article, there was found a significant difference in logistic Euroscore between SAVR/CABG (21.0% ± 17.5%) and TAVR/PCI group (36.1% ± 18.9%) with P < .001 16 …”

“…Three articles were selected for final meta‐analysis, one paper was excluded as it presented earlier outcomes of one of the selected studies. Among the included one was an RCT, 14 one national observational, prospective, multicentre, cohort propensity score match study, 15 and one a prospective registry analysis 16 …”

“…The percutaneous revascularization approach differed significantly among studies. Sondergaard et al, advocated for simultaneous or staged approach (with median duration of 6 days between PCI and TAVR), 14 Barbanti et al selected patients with concomitant or staged PCI less than 6 months before TAVR, 15 and Baumbach et al 16 selected only patients with staged PCI performed less than 12 months before TAVR.…”

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

“…A total of six studies met inclusion criteria evaluating 1770 participants of which 631 had TAVR and PCI and 1,139 had SAVR and CABG were included in the meta‐analysis (Figure 1, Table 1). 14‐19 The mean age was 79.2 years and 41.1% of participants were female in studies reporting age 14‐19 and gender 14,16,17,19 respectively (Table 2). Patients in both the SAVR and CABG, and the TAVR and PCI groups were of high operative risk in five studies 14,15,17‐19 and of intermediate operative risk in the SURTAVI analysis (Table 2).…”

“… 14‐19 The mean age was 79.2 years and 41.1% of participants were female in studies reporting age 14‐19 and gender 14,16,17,19 respectively (Table 2). Patients in both the SAVR and CABG, and the TAVR and PCI groups were of high operative risk in five studies 14,15,17‐19 and of intermediate operative risk in the SURTAVI analysis (Table 2). 16 The extent of CAD was reported in three studies, 14,16,19 while the anatomical severity as assessed by the SYNTAX score in one study.…”