Key result
Transapical transcatheter aortic valve replacement was associated with a higher unadjusted hazard of all-cause mortality (HR 3.15) compared to surgical replacement, but survival was comparable after propensity matching.
Why the study?
Does transapical transcatheter aortic valve replacement improve 30-day mortality and VARC-2 outcomes compared to surgical aortic valve replacement in elderly patients with previous CABG?
Cohort (n=239)
Yes
Does transapical transcatheter aortic valve replacement improve 30-day mortality and VARC-2 outcomes compared to surgical aortic valve replacement in elderly patients with previous CABG?
Hazard Ratio: 3.15 (95% CI 1.28–6.62)
p-value: p=<0.01
In elderly patients with previous CABG, transapical TAVR and surgical AVR offer comparable 30-day outcomes after propensity matching, though TAVR may be preferable for patients at high perioperative renal risk.
Matched survival supports considering transapical TAVR in prior CABG; leaves open randomized confirmation of outcomes.
OBJECTIVES: To evaluate the results of aortic valve replacement through sternotomic approach in redo scenarios (RAVR) vs transapical transcatheter aortic valve replacement (TAVR), in patients in the eighth decade of life or older already undergone previous coronary artery bypass grafting (CABG). METHODS: One hundred and twenty-six patients undergoing RAVR were compared with 113 patients undergoing TaTAVR in terms of 30-day mortality and Valve Academic Research Consortium-2 outcomes. The two groups were also analysed after propensity-matching. RESULTS: TaTAVR patients demonstrated a higher incidence of 30-day mortality (P = 0.03), stroke (P = 0.04), major bleeding (P = 0.03), worse 'early safety' (P = 0.04) and lower permanent pacemaker implantation (P = 0.03). TaTAVR had higher follow-up hazard in all-cause mortality [hazard ratio (HR) 3.15, 95% confidence interval (CI) 1.28-6.62; P < 0.01] and cardiovascular mortality (HR 1.66, 95% CI 1.02-4.88; P = 0.04). Propensity-matched patients showed comparable 30-day outcome in terms of survival, major morbidity and early safety, with only a lower incidence of transfusions after TaTAVR (10.7% vs RAVR: 57.1%; P < 0.01). A trend towards lower Acute Kidney Injury Network Classification 2/3 (3.6% vs RAVR 21.4%; P = 0.05) and towards a lower freedom from all-cause mortality at follow-up (TaTAVR: 44.3 ± 21.3% vs RAVR: 86.6 ± 9.3%; P = .08) was demonstrated after TaTAVR, although cardiovascular mortality was comparable (TaTAVR: 86.5 ± 9.7% vs RAVR: 95.2 ± 4.6%; P = 0.52). Follow-up freedom from stroke, acute heart failure, reintervention on AVR and thrombo-embolisms were comparable (P = NS). EuroSCORE II (P = 0.02), perioperative stroke (P = 0.01) and length of hospitalization (P = 0.02) were the determinants of all-cause mortality at follow-up, whereas perioperative stroke (P = 0.03) and length of hospitalization (P = 0.04) impacted cardiovascular mortality at follow-up. CONCLUSIONS: Reported differences in mortality and morbidity after TaTAVR and RAVR reflect differences in baseline risk profiles. Given the lower trend for renal complications, patients at higher perioperative renal risk might be better served by TaTAVR.
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Onorati et al. (2016) conducted a cohort in Aortic valve stenosis with previous coronary artery bypass grafting (n=239). Transapical transcatheter aortic valve replacement (TaTAVR) vs. Surgical aortic valve replacement (RAVR) was evaluated on All-cause mortality at follow-up (unadjusted) (HR 3.15, 95% CI 1.28-6.62, p=<0.01). Transapical transcatheter aortic valve replacement was associated with a higher unadjusted hazard of all-cause mortality (HR 3.15) compared to surgical replacement, but survival was comparable after propensity matching.
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