Abstract
BackgroundCoronary 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.MethodsA 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.Results464 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).ConclusionsTAVR+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.
Highlights
Coronary artery disease (CAD) is associated with poorer outcomes after aortic valve replacement (AVR)
New York heart association (NYHA) class III/IV was most common in the transcatheter aortic valve replacement (TAVR)+percutaneous coronary intervention (PCI) group, followed by the TAVR+OP/minimally invasive direct CABG (MIDCAB) and surgical aortic valve replacement (SAVR)+coronary artery bypass grafting (CABG) groups (p < 0.001), with the same trend seen for SAVR + CABG
In-hospital mortality was highest for TAVR+OP/MIDCAB patients with rates comparable between TAVR+PCI and SAVR+CABG patients (18.0% vs. 9.0 and 6.9%; p = 0.009)
Summary
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 offpump/minimally-invasive coronary artery bypass (OPCAB/MIDCAB) has been proposed. An estimated 40–75% of the severe aortic stenosis (AS) patients who undergo transcatheter aortic valve replacement (TAVR) have concomitant coronary artery disease (CAD) [1]. In patients with a primary indication for surgical aortic valve replacement (SAVR), a history of coronary artery bypass grafting (CABG) increases operative risk; to diminish this effect, guidelines recommend combination of both procedures into one hybrid operation [2]. Off-pump CABG (OPCAB) has been proposed as a method of complete coronary revascularisation in patients with complex stenosis and/or high SYNTAX scores [5, 6], with the off-pump technique avoiding the harmful effects of cardiopulmonarybypass (CPB) [7]. Only one larger study has evaluated the safety and feasibility of TAVR+OPCAB/MIDCAB to date [11], and no comparisons with TAVR+PCI and SAVR+CABG have been performed
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