Optimal Management for Moderate Aortic Stenosis at the Time of Coronary Artery Bypass Grafting

BACKGROUND: Established guidelines recommend consideration for concomitant surgical aortic valve replacement (SAVR) at time of coronary artery bypass grafting (CABG) in patients with moderate aortic stenosis (AS) to avoid future reoperation for AS progression. The advent of transcatheter aortic valve replacement allows for treatment of AS without mediastinal entry. This questions the optimal treatment choice of moderate AS in patients undergoing CABG. We compared outcomes of CABG with or without SAVR in patients with moderate AS. METHODS: Patients ≥65 years old with moderate AS who underwent CABG or CABG+SAVR from 2011-2022 were identified from the Society of Thoracic Surgeons adult cardiac surgery database. Exclusions included cardiogenic shock, endocarditis, severe aortic insufficiency, and non-sternotomy cases. Analyzed outcomes included perioperative complications, mid-term mortality, and readmission for heart failure or aortic valve (AV) intervention. RESULTS: Among 18,247 patients, 9,325(51.1%) underwent CABG+SAVR and 8,922(48.9%) underwent isolated CABG. The isolated CABG cohort had lower operative mortality and postoperative complications. Risk adjusted mid-term outcomes showed similar all-cause mortality. Patients who underwent isolated CABG were at an increased risk for mid-term readmission for heart failure and AV intervention. Rate of AV intervention at 8 years for isolated CABG patients compared to CABG+SAVR was 25.9% versus 2.4%, respectively. CONCLUSIONS: Deferring SAVR during CABG in patients with moderate AS may lower operative risk without affecting mid-term mortality but increases heart failure readmissions and later AV interventions. Further studies are needed to determine if delaying the AV intervention translates to reduced prosthetic valve degeneration without increasing long-term morbidity and mortality.