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Thorac Cardiovasc Surg 2023; 71(08): 620-631
DOI: 10.1055/a-2003-2105
Original Cardiovascular

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

Ahmed Elderia 
1   Department of Cardiothoracic Surgery, University of Cologne, Heart Center, Cologne, Germany
,
Stephen Gerfer 
1   Department of Cardiothoracic Surgery, University of Cologne, Heart Center, Cologne, Germany
,
Kaveh Eghbalzadeh 
1   Department of Cardiothoracic Surgery, University of Cologne, Heart Center, Cologne, Germany
,
Matti Adam
2   Department of Cardiology, University of Cologne, Heart Center, Cologne, Germany
,
Stephan Baldus
2   Department of Cardiology, University of Cologne, Heart Center, Cologne, Germany
,
Parwis Rahmanian
1   Department of Cardiothoracic Surgery, University of Cologne, Heart Center, Cologne, Germany
,
Elmar Kuhn   *
1   Department of Cardiothoracic Surgery, University of Cologne, Heart Center, Cologne, Germany
,
Thorsten Wahlers   *
1   Department of Cardiothoracic Surgery, University of Cologne, Heart Center, Cologne, Germany
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Abstract

Background Coronary artery disease (CAD) is frequently diagnosed in patients with aortic valve stenosis. Treatment options include surgical and interventional approaches. We therefore analyzed short-term outcomes of patients undergoing either coronary artery bypass grafting with simultaneous aortic valve replacement (CABG + AVR) or staged percutaneous coronary intervention and transcatheter aortic valve implantation (PCI + TAVI).

Methods From all patients treated since 2017, we retrospectively identified 237 patients undergoing TAVI within 6 months after PCI and 241 patients undergoing combined CABG + AVR surgery. Propensity score matching was performed, resulting in 101 matched pairs.

Results Patients in the CABG + AVR group were younger compared with patients in the PCI + TAVI group (71.9 ± 4.9 vs 81.4 ± 3.6 years; p < 0.001). The overall mortality at 30 days before matching was higher after CABG + AVR than after PCI + TAVI (7.8 vs 2.1%; p = 0.012). The paired cohort was balanced for both groups regarding demographic variables and the risk profile (age: 77.2 ± 3.7 vs78.5 ± 2.7 years; p = 0.141) and EuroSCORE II (6.2 vs 7.6%; p = 0.297). At 30 days, mortality was 4.9% in the CABG + AVR group and 1.0% in the PCI + TAVI group (p = 0.099). Rethoracotomy was necessary in 7.9% in the CABG + AVR, while conversion to open heart surgery was necessary in 2% in the PCI + TAVI group. The need for new pacemaker was lower after CABG + AVR than after PCI + TAVI (4.1 vs 6.9%; p = 0.010). No paravalvular leak (PVL) was noted in the CABG + AVR group, while the incidence of moderate-to-severe PVL after PCI + TAVI was 4.9% (p = 0.027).

Conclusion A staged interventional approach comprises a short-term survival advantage compared with combined surgery for management of CAD and aortic stenosis. However, PCI + TAVI show a significantly higher risk of atrioventricular block and PVL. Further long-term trials are warranted.

Keywords

coronary artery bypass grafts surgery - CABG - heart valve surgery - heart valve - transapical - percutaneous (TAVI) - cardiac catheterization/intervention (incl. PCI)

Authors' Contribution

A.E. contributed to study design, data collection, data analysis, interpretation, and writing of the manuscript. S.G., K.E. and M.A. contributed to data collection and data analysis. P.R. and S.B. contributed to data collection and interpretation. E.K. and T.W. contributed equally to data analysis and interpretation, review, and correction of the manuscript.




Publication History

Received: 22 September 2022

Accepted: 15 December 2022

Accepted Manuscript online:
22 December 2022

Article published online:
03 February 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Abdel-Wahab M, Abdelghani M, Miyazaki Y. et al. A novel angiographic quantification of aortic regurgitation after TAVR provides an accurate estimation of regurgitation fraction derived from cardiac magnetic resonance imaging. JACC Cardiovasc Interv 2018; 11 (03) 287-297
    CrossrefPubMedGoogle Scholar
  • 2 Walther T, Hamm CW, Schuler G. et al; GARY Executive Board. Perioperative results and complications in 15,964 transcatheter aortic valve replacements: prospective data from the GARY registry. J Am Coll Cardiol 2015; 65 (20) 2173-2180
    CrossrefPubMedGoogle Scholar
  • 3 Baumbach H, Schairer ER, Wachter K. et al. 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. BMC Cardiovasc Disord 2019; 19 (01) 108
    CrossrefPubMedGoogle Scholar
  • 4 Baumgartner H, Cremer J, Eggebrecht H. et al. Kommentar zu den Leitlinien (2017) der ESC/EACTS zum Management von Herzklappenerkrankungen. Der Kardiologe 2018; 12 (03) 184-193
    CrossrefPubMedGoogle Scholar
  • 5 Vahanian A, Beyersdorf F, Praz F. et al; ESC/EACTS Scientific Document Group. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2021; 60 (04) 727-800
    CrossrefPubMedGoogle Scholar
  • 6 Hamm CW, Beyersdorf F. GARY-the largest registry of aortic stenosis treatment worldwide. Eur Heart J 2020; 41 (06) 733-735
    CrossrefPubMedGoogle Scholar
  • 7 Lund O, Nielsen TT, Pilegaard HK, Magnussen K, Knudsen MA. The influence of coronary artery disease and bypass grafting on early and late survival after valve replacement for aortic stenosis. J Thorac Cardiovasc Surg 1990; 100 (03) 327-337
    CrossrefPubMedGoogle Scholar
  • 8 Falk V, Baumgartner H, Bax JJ. et al; ESC Scientific Document Group. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2017; 52 (04) 616-664
    CrossrefPubMedGoogle Scholar
  • 9 Neumann F-J, Sousa-Uva M, Ahlsson A. et al; ESC Scientific Document Group. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J 2019; 40 (02) 87-165
    CrossrefPubMedGoogle Scholar
  • 10 Généreux P, Stone GW, O'Gara PT. et al. Natural history, diagnostic approaches, and therapeutic strategies for patients with asymptomatic severe aortic stenosis. J Am Coll Cardiol 2016; 67 (19) 2263-2288
    CrossrefPubMedGoogle Scholar
  • 11 Généreux P, Piazza N, Alu MC. et al; VARC-3 WRITING COMMITTEE. Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research. Eur Heart J 2021; 42 (19) 1825-1857
    CrossrefPubMedGoogle Scholar
  • 12 Thygesen K, Alpert JS, Jaffe AS. et al; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol 2018; 72 (18) 2231-2264
    CrossrefPubMedGoogle Scholar
  • 13 Baumgartner H, Hung J, Bermejo J. et al; American Society of Echocardiography, European Association of Echocardiography. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 2009; 22 (01) 1-23 , quiz 101–102
    CrossrefPubMedGoogle Scholar
  • 14 Bonow RO, Carabello BA, Chatterjee K. et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 52 (13) e1-e142
    CrossrefPubMedGoogle Scholar
  • 15 Herzstiftung D. 32 Deutscher Herzbericht 2020. 2021. This is available at https://www.herzstiftung.de/system/files/2021-06/Deutscher-Herzbericht-2020.pdf
    PubMed
  • 16 Kotronias RA, Bray JH, Scarsini R. et al. 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. Catheter Cardiovasc Interv 2020; 96 (05) 1113-1125
    CrossrefPubMedGoogle Scholar
  • 17 Tarus A, Tinica G, Bacusca A, Artene B, Popa IV, Burlacu A. 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). J Card Surg 2020; 35 (08) 2009-2016
    CrossrefPubMedGoogle Scholar
  • 18 Søndergaard L, Popma JJ, Reardon MJ. et al. SURTAVI Trial Investigators. (2019). Comparison of a complete percutaneous versus surgical approach to aortic valve replacement and revascularization in patients at intermediate surgical risk: results from the randomized SURTAVI Trial. Circulation 140 (16) 1296-1305
    CrossrefPubMedGoogle Scholar
  • 19 Alperi A, Mohammadi S, Campelo-Parada F. et al. Transcatheter versus surgical aortic valve replacement in patients with complex coronary artery disease. JACC Cardiovasc Interv 2021; 14 (22) 2490-2499
    CrossrefPubMedGoogle Scholar
  • 20 Patterson T, Clayton T, Dodd M. et al; ACTIVATION Trial Investigators. ACTIVATION (PercutAneous Coronary inTervention prIor to transcatheter aortic VAlve implantaTION): a randomized clinical trial. JACC Cardiovasc Interv 2021; 14 (18) 1965-1974
    CrossrefPubMedGoogle Scholar
  • 21 Khan M, Senguttuvan NB, Krishnamoorthy P. et al. Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement with medtronic self-expanding prosthesis: Insights from correlations with computer tomography. Int J Cardiol 2020; 317: 18-24
    CrossrefPubMedGoogle Scholar
  • 22 Tsai LL, Jensen HA, Thourani VH. The aged and the ill: a decade of surgical aortic valve replacement outcomes. J Thorac Cardiovasc Surg 2015; 150 (03) 579-580
    CrossrefPubMedGoogle Scholar
  • 23 Kuck K-H, Bleiziffer S, Eggebrecht H. et al. Consensus paper of the German Cardiac Society (DGK) and the German Society for Thoracic and Cardiovascular Surgery (DGTHG) on transcatheter aortic valve implantation (TAVI) 2020. Der Kardiologe 2020; 14: 182-204
    CrossrefPubMedGoogle Scholar
  • 24 Fischlein T, Folliguet T, Meuris B. et al; Perceval Sutureless Implant Versus Standard-Aortic Valve Replacement Investigators. Sutureless versus conventional bioprostheses for aortic valve replacement in severe symptomatic aortic valve stenosis. J Thorac Cardiovasc Surg 2021; 161 (03) 920-932
    CrossrefPubMedGoogle Scholar
  • 25 Halapas A, Chrissoheris M, Tzifa A. et al. Paravalvular leak closure: work-up, techniques and results. Continuing Cardiol Educ 2016; 2 (01) 47-51
    CrossrefPubMedGoogle Scholar
  • 26 Pibarot P, Hahn RT, Weissman NJ, Monaghan MJ. Assessment of paravalvular regurgitation following TAVR: a proposal of unifying grading scheme. JACC Cardiovasc Imaging 2015; 8 (03) 340-360
    CrossrefPubMedGoogle Scholar
  • 27 Chevreul K, Brunn M, Cadier B. et al; FRANCE registry investigators. Cost of transcatheter aortic valve implantation and factors associated with higher hospital stay cost in patients of the FRANCE (FRench Aortic National CoreValve and Edwards) registry. Arch Cardiovasc Dis 2013; 106 (04) 209-219
    CrossrefPubMedGoogle Scholar
  • 28 Ensminger S, Fujita B, Bauer T. et al; GARY Executive Board. Rapid deployment versus conventional bioprosthetic valve replacement for aortic stenosis. J Am Coll Cardiol 2018; 71 (13) 1417-1428
    CrossrefPubMedGoogle Scholar