Wendt and associates [1Wendt D. Kahlert P. Lenze T. et al.Management of high-risk patients with aortic stenosis and coronary artery disease.Ann Thorac Surg. 2013; 95: 599-605Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar] retrospectively examine the outcomes of percutaneous intervention (PCI)-first staged hybrid treatment of concomitant aortic stenosis and coronary artery disease (CAD) with transcatheter aortic valve replacement (TAVR) in a high-surgical-risk population using a propensity score analysis. Surprisingly, the 30-day mortality was not superior for the catheter-based treatment group compared with the surgical group (11.9% vs 12.5%). The lack of a difference may be related to the inclusion of learning curve TAVR cases, different risk profiles between the two intervention groups not included in the propensity analysis, or the timing of procedures in the staged hybrid arm, or it may suggest that very-high-risk populations carry a high procedural risk regardless of the intervention performed. Nevertheless, their 30-day mortality is in line with prior studies of high-surgical-risk patients with CAD undergoing TAVR (13.3%) [2Dewey T.M. Brown D.L. Herbert M.A. et al.Effect of concomitant coronary artery disease on procedural and late outcomes of transcatheter aortic valve implantation.Ann Thorac Surg. 2010; 89 (discussion 767): 758-767Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar] and of high-risk aortic stenosis patients undergoing PCI alone (15.4%) [3Goel S.S. Agarwal S. Tuzcu E.M. et al.Percutaneous coronary intervention in patients with severe aortic stenosis: implications for transcatheter aortic valve replacement.Circulation. 2012; 125: 1005-1013Crossref PubMed Scopus (92) Google Scholar].There are differences in baseline patient characteristics that could adversely affect the outcomes in the catheter group, including increased risk of mortality, based on the Society of Thoracic Surgeons' (STS) and the European System for Cardiac Operative Risk Evaluation (EuroSCORE) predictive risk models, more patients with peripheral arterial disease and diabetes, and a lower mean left ventricular ejection fraction. Patients with diabetes and low ejection fraction are historically among those who benefit most from surgical revascularization. However, patients in the surgical group had more extensive CAD, which was also reflected by a greater number of vessels revascularized surgically. Unfortunately, left internal mammary artery use in the surgical group was only 70.7%. The concept of what constitutes significant CAD is trivialized in this study, and was not included in the propensity analysis, yet may be one of the most important details driving the success of the procedure in question. The degree to which CAD results in myocardial ischemia and lesion complexity affects which patients require concomitant coronary intervention, dictates technical difficulty for both PCI and surgical procedures, and affects short-term and long-term outcomes. Leacche and colleagues [4Leacche M. Byrne J.G. Solenkova N.S. et al.Comparison of 30-day outcomes of coronary artery bypass grafting surgery versus hybrid coronary revascularization stratified by SYNTAX and euroSCORE.J Thorac Cardiovasc Surg. 2012 Apr 25; ([E-pub ahead of print])Google Scholar] recently demonstrated that the complexity of angiographic coronary lesions in addition to surgical risk dramatically affects the short-term outcome of hybrid coronary revascularization.Among the important findings of this study is that the authors begin to tease out which patients benefit most from this novel treatment strategy, specifically the impact of left ventricular ejection fraction. As the use of TAVR continues to expand and includes patients with CAD, which patient groups benefit from variations of this procedure needs to be elucidated. The current study demonstrates that a catheter-based hybrid approach to concomitant aortic stenosis and CAD in high-risk patients can be carried out with similar mortality as that of a traditional surgical approach. Wendt and associates [1Wendt D. Kahlert P. Lenze T. et al.Management of high-risk patients with aortic stenosis and coronary artery disease.Ann Thorac Surg. 2013; 95: 599-605Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar] retrospectively examine the outcomes of percutaneous intervention (PCI)-first staged hybrid treatment of concomitant aortic stenosis and coronary artery disease (CAD) with transcatheter aortic valve replacement (TAVR) in a high-surgical-risk population using a propensity score analysis. Surprisingly, the 30-day mortality was not superior for the catheter-based treatment group compared with the surgical group (11.9% vs 12.5%). The lack of a difference may be related to the inclusion of learning curve TAVR cases, different risk profiles between the two intervention groups not included in the propensity analysis, or the timing of procedures in the staged hybrid arm, or it may suggest that very-high-risk populations carry a high procedural risk regardless of the intervention performed. Nevertheless, their 30-day mortality is in line with prior studies of high-surgical-risk patients with CAD undergoing TAVR (13.3%) [2Dewey T.M. Brown D.L. Herbert M.A. et al.Effect of concomitant coronary artery disease on procedural and late outcomes of transcatheter aortic valve implantation.Ann Thorac Surg. 2010; 89 (discussion 767): 758-767Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar] and of high-risk aortic stenosis patients undergoing PCI alone (15.4%) [3Goel S.S. Agarwal S. Tuzcu E.M. et al.Percutaneous coronary intervention in patients with severe aortic stenosis: implications for transcatheter aortic valve replacement.Circulation. 2012; 125: 1005-1013Crossref PubMed Scopus (92) Google Scholar]. There are differences in baseline patient characteristics that could adversely affect the outcomes in the catheter group, including increased risk of mortality, based on the Society of Thoracic Surgeons' (STS) and the European System for Cardiac Operative Risk Evaluation (EuroSCORE) predictive risk models, more patients with peripheral arterial disease and diabetes, and a lower mean left ventricular ejection fraction. Patients with diabetes and low ejection fraction are historically among those who benefit most from surgical revascularization. However, patients in the surgical group had more extensive CAD, which was also reflected by a greater number of vessels revascularized surgically. Unfortunately, left internal mammary artery use in the surgical group was only 70.7%. The concept of what constitutes significant CAD is trivialized in this study, and was not included in the propensity analysis, yet may be one of the most important details driving the success of the procedure in question. The degree to which CAD results in myocardial ischemia and lesion complexity affects which patients require concomitant coronary intervention, dictates technical difficulty for both PCI and surgical procedures, and affects short-term and long-term outcomes. Leacche and colleagues [4Leacche M. Byrne J.G. Solenkova N.S. et al.Comparison of 30-day outcomes of coronary artery bypass grafting surgery versus hybrid coronary revascularization stratified by SYNTAX and euroSCORE.J Thorac Cardiovasc Surg. 2012 Apr 25; ([E-pub ahead of print])Google Scholar] recently demonstrated that the complexity of angiographic coronary lesions in addition to surgical risk dramatically affects the short-term outcome of hybrid coronary revascularization. Among the important findings of this study is that the authors begin to tease out which patients benefit most from this novel treatment strategy, specifically the impact of left ventricular ejection fraction. As the use of TAVR continues to expand and includes patients with CAD, which patient groups benefit from variations of this procedure needs to be elucidated. The current study demonstrates that a catheter-based hybrid approach to concomitant aortic stenosis and CAD in high-risk patients can be carried out with similar mortality as that of a traditional surgical approach. Management of High-Risk Patients With Aortic Stenosis and Coronary Artery DiseaseThe Annals of Thoracic SurgeryVol. 95Issue 2PreviewAortic valve replacement with coronary artery bypass graft surgery is currently the standard therapy for patients with aortic stenosis and concomitant coronary artery disease. We sought to determine whether transcatheter aortic valve implantation combined with percutaneous coronary intervention might be an equivalent strategy. Full-Text PDF