Transcatheter aortic valve replacement has improved short-term but similar midterm outcomes in isolated aortic valve replacement after prior coronary artery bypass grafting

Comparison of rehabilitation outcomes for transcatheter versus surgical aortic valve replacement as redo procedure in patients with previous cardiac surgery: Evidence based on 11 observational studies

BACKGROUND

Currently, the number of severe aortic stenosis (AS) patients with a history of prior cardiac surgery (PCS) has increased. Both transcatheter aortic valve replacement (TAVR) and traditional surgical aortic valve replacement (sAVR) are effective therapy for AS. However, PCS increases the risk of adverse outcomes in patients undergoing aortic valve replacement. Thus, this meta-analysis was designed to comparatively evaluate the impact of PCS on clinical outcomes between TAVR and sAVR.

METHODS

A systematic search of PubMed, Embase, Cochrane Library, and Web of Science up to February 1, 2021 was conducted for relevant studies that comparing TAVR and sAVR for severe AS patients with a history of PCS. The primary outcome was the non-inferiority of TAVR and sAVR in mortality. The secondary outcomes were the other clinical outcomes. Two reviewers assessed trial quality and extracted the data independently. All statistical analyses were performed using the standard statistical procedures provided in Review Manager 5.2.

RESULTS

A total of 11 studies including 8852 patients were identified. The pooled results indicated that there was no difference in 30-day, and 1-year all-cause mortality between TAVR and sAVR. No significant difference was also observed in total follow-up and cardiovascular mortality between TAVR and sAVR. However, subgroup analysis revealed significantly higher 1-year all-cause mortality (OR 1.92; 95% CI 1.05-3.52; P = .04) and total follow-up mortality (OR 2.28; 95% CI 1.09-4.77; P = .03) in TAVR than sAVR for patients with a history of coronary artery bypass graft, aortic valve replacement, and mitral valve reconstruction. In addition, TAVR experienced higher pacemaker implantation than sAVR. However, compared with sAVR, TAVR experienced shorter length of stay (MD -3.18 days; 95% CI -4.78 to -1.57 days) and procedural time (MD -172.01 minutes; 95% CI -251.15 to -92.88) respectively. TAVR also lead to much less bleeding than sAVR.

CONCLUSIONS

Our analysis shows that TAVR as a redo procedure was equal to sAVR in mortality for severe AS patients with PCS, especially coronary artery bypass graft. We agree the advantage of TAVR as a redo procedure for patients with a history of PCS. Patients receiving TAVR experienced rapid recovery, shorter operation time and less bleeding, without increasing short and long term mortality.

Transcatheter and Surgical Aortic Valve Replacement in Patients With Previous Cardiac Surgery: A Meta-Analysis

Background: Many patients who have aortic stenosis and are transcatheter aortic valve replacement (TAVR) candidates have underwent prior cardiac surgery (PCS). The aim of this study was to provide a robust summary comparison between patients with PCS who underwent TAVR vs. surgical aortic valve replacement (SAVR).

Methods: We conducted a systematic review and meta-analysis of all published articles on PubMed/Medline, Ovid, EMBASE, and Scopus from 2002 to 2019.

Results: A total of 13 studies were finally included, yielding a total of 23,148 participants. There was no statistical difference with 30-day [OR: 1.02 (0.86–1.21)] or 1-year mortality [OR: 1.18 (0.86–1.61)] between the two groups. Subgroup analysis revealed that high-risk patients who underwent TAVR with the transapical approach were associated with increased risk of mortality [OR: 1.45 (1.00–2.11)]. However, those who underwent TAVR with endovascular approach had a comparable outcome with SAVR.

Conclusions: Primary outcomes after endovascular TAVR were similar to those with SAVR and superior to transapical TAVR treatment group in patients with PCS.

Adverse clinical outcomes in patients undergoing both PCI and TAVR: Analysis from a pooled multi-center registry

BACKGROUND

There is a paucity of data regarding the optimum timing of PCI in relation to TAVR.

OBJECTIVE

We compared the major adverse cardiovascular and cerebrovascular events (MACCE) rates among patients who underwent percutaneous coronary intervention (PCI) before transcatheter aortic valve replacement (TAVR) with those who received PCI with/after TAVR.

METHODS

In this multicenter study, we pooled all consecutive patients who underwent TAVR at three high volume centers.

RESULTS

Among 3,982 patients who underwent TAVR, 327 (8%) patients underwent PCI within 1 year before TAVR, 38 (1%) had PCI the same day as TAVR and 15 (0.5%) had PCI within 2 months after TAVR. Overall, among patients who received both PCI and TAVR (n = 380), history of previous CABG (HR:0.501; p = .001), higher BMI at TAVR (HR:0.970; p = .038), and statin therapy after TAVR (HR:0.660, p = .037) were independently associated with lower MACCE while warfarin therapy after TAVR was associated with a higher risk of MACCE (HR:1.779, p = .017). Patients who received PCI within 1 year before TAVR had similar baseline demographics, STS scores, clinical risk factors when compared to patients receiving PCI with/after TAVR. Both groups were similar in PCI (Syntax Score, ACC/AHA lesion class) and TAVR (valve types, access) related variables. There were no significant differences in terms of MACCE (log rank p = .550), all-cause mortality (log rank p = .433), strokes (log rank p = .153), and repeat PCI (log rank p = .054) in patients who underwent PCI with/after TAVR when compared to patients who received PCI before TAVR.

CONCLUSION

Among patients who underwent both PCI and TAVR, history of CABG, higher BMI, and statin therapy had lower, while those discharged on warfarin, had higher adverse event rates. Adverse events rates were similar regardless of timing of PCI.

Outcome of patients with previous coronary artery bypass grafting and severe calcific aortic stenosis receiving transfemoral transcatheter aortic valve replacement

OBJECTIVES

To evaluate the impact of previous coronary artery bypass grafting (CABG) on early safety at 30 days and 1-year mortality in patients receiving transcatheter aortic valve replacement (TAVR).

BACKGROUND

The use of TAVR in patients with previous CABG suffering from severe aortic stenosis has increased in the last years.

METHODS

Consecutive TAVR patients were stratified according to previous CABG versus no previous cardiac surgery (control). All-cause 1-year mortality and early safety at 30 days were evaluated.

RESULTS

In the unmatched cohort and compared to control (n = 2,364), CABG (n = 260) were younger, more often male and suffered more often from comorbidities leading to an increased STS-score (p < .001). The rate of early safety events at 30 days was comparable between CABG and control (21.2% vs. 24.6%, p = .22) with a higher mortality in CABG (9.6% vs. 5.3%, p = .005). All-cause 1-year mortality was higher in CABG compared to controls (HR 1.51 [95%-CI 1.15-1.97], p = .003). Applying Cox regression analysis, both 30-day (HR 1.57 [95%-CI 0.97-2.53], p = .067) and all-cause 1-year mortality (HR 1.24 [95%-CI 0.91-1.70], p = .174) were not significantly different between groups. After propensity-score matching, the rate of early safety events at 30 days was lower in CABG compared to controls (21.6% vs. 31.7%, p = .02). Thirty-day (9.1% vs. 7.7%, p = .596) and all-cause 1-year mortality (24.0% vs. 23.1%, p = .520, HR 1.14 [95%-CI 0.77-1.69], p = .520) were not different between groups.

CONCLUSION

In patients receiving TAVR, previous CABG was not associated with an increase in periprocedural complications and all-cause 1-year mortality when adjusted for other comorbidities.

A meta-analysis of ≥5-year mortality after transcatheter versus surgical aortic valve replacement

INTRODUCTION

It remains unclear whether long-term survival is superior following transcatheter aortic valve implantation (TAVI) than following surgical aortic valve replacement (SAVR). We performed a meta-analysis of mortality with ≥5-year follow-up in randomized controlled trials (RCTs) and propensity-score matched (PSM) studies of TAVI versus SAVR.

EVIDENCE ACQUISITION

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched through March 2019. Eligible studies were RCTs or PSM studies of TAVI versus SAVR enrolling patients with severe aortic stenosis and reporting all-cause mortality with ≥5-year follow-up as an outcome. A hazard ratio of mortality for TAVI versus SAVR was extracted from each individual study.

EVIDENCE SYNTHESIS

Our search identified 3 RCTs and 7 PSM studies enrolling 5498 patients. A pooled analysis of all 10 studies demonstrated a statistically significant 38% increase in mortality with TAVI relative to SAVR. A subgroup meta-analysis showed no statistically significant difference between TAVI and AVR in RCTs and a statistically significant 68% increase with TAVI relative to SAVR in PSM studies.

CONCLUSIONS

On the basis of a meta-analysis of 7 PSM studies, TAVI is associated with greater all-cause mortality with ≥5-year follow-up than SAVR. However, another meta-analysis of 3 RCTs suggests no difference in mortality between TAVI and SAVR.

Left Ventricular Function Recovery After Transapical TAVR in Patients With Previous Coronary Artery Bypass Graft Surgery

OBJECTIVE

The transapical (TA) approach is an alternative access technique for transcatheter aortic valve replacement (TAVR) in patients with symptomatic aortic valve stenosis. The impact of prior coronary artery bypass graft (CABG) surgery and how it affects left ventricular function recovery is not well defined.

METHODS

Patients who had TAVR at a single center between June 2012 and December 2016 were reviewed. High-risk patients who underwent the procedure via a TA approach were divided into 2 groups based on their history of CABG surgery. Postoperative outcomes were compared between groups. CABG/TA-TAVR patients were subdivided into 2 per baseline left ventricular ejection fraction (LVEF) <50%. The changes in LVEF and valve function at follow-up (1 to 12 months) were analyzed using paired t-tests.

RESULTS

Of 923 cases in total, 183 (19.8%) were performed via a TA approach. The mean ± SD Society of Thoracic Surgeons risk score of TA patients was 10.2 ± 4.6. Forty-nine (27%) had a surgical history of CABG. Overall all-cause mortality rates at 30 days, 1 year, and 2 years were similar for both groups (P = 0.59, P = 0.64, P = 0.78). Subgrouping of CABG-TAVR patients (n = 49) identified 24 patients (49%) with LVEF ≥50% vs. 25 (51%) with LVEF <50%. At 1-year follow-up, significant improvements in LVEF (low LVEF group) and valve function for both groups were observed. LVEF ≥50% group (LVEF: ∆: -3%, P = 0.878; aortic valve area [AVA]: ∆: 1.3 cm^2, P < 0.001; mean gradient: ∆: -38 mmHg, P < 0.001); LVEF <50% group (LVEF: ∆: 10%, P = 0.01; AVA: ∆: 1.3 cm², P < 0.001; MG: ∆: -31 mmHg, P < 0.001).

CONCLUSIONS

TA-TAVR can be safely performed with acceptable postoperative outcomes in patients with a history of CABG surgery. In those with reduced EF, significant improvements in LV and valve functions are seen at 1-year follow-up.

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Prior Coronary Artery Bypass Grafting: Trends in Utilization and Propensity-Matched Analysis of In-Hospital Outcomes

BACKGROUND

A significant proportion of patients requiring aortic valve replacement (AVR) have undergone prior coronary artery bypass grafting (CABG). Reoperative heart surgery is associated with increased risk. Data on relative utilization and comparative outcomes of transcatheter (TAVR) versus surgical AVR (SAVR) in patients with prior CABG are limited.

METHODS AND RESULTS

We queried the 2012 to 2014 National Inpatient Sample databases to identify isolated AVR hospitalizations in adults with prior CABG. In-hospital outcomes of TAVR versus SAVR were compared using propensity-matched analysis. Of 147 395 AVRs, 15 055 (10.2%) were in patients with prior CABG. The number of TAVRs in patients with prior CABG increased from 1615 in 2012 to 4400 in 2014, whereas the number of SAVRs decreased from 2285 to 1895 (P_trend<0.001). There were 3880 records in each group in the matched cohort. Compared with SAVR, TAVR was associated with similar in-hospital mortality (2.3% versus 2.4%; P=0.71) but lower incidence of myocardial infarction (1.5% versus 3.4%; P<0.001), stroke (1.4% versus 2.7%; P<0.001), bleeding complications (10.6% versus 24.6%; P<0.001), and acute kidney injury (16.2% versus 19.3%; P<0.001). Requirement for prior permanent pacemaker was higher in the TAVR cohort, whereas the incidence of vascular complications and acute kidney injury requiring dialysis was similar in the 2 groups. Average length of stay was shorter in patients undergoing TAVR.

CONCLUSIONS

TAVR is being increasingly used as the preferred modality of AVR in patients with prior CABG. Compared with SAVR, TAVR is associated with similar in-hospital mortality but lower rates of in-hospital complications in this important subset of patients.

Management of Less-Than-Severe Aortic Stenosis During Coronary Bypass: A Systematic Review and Meta-Analysis

OBJECTIVE

The management of concomitant mild-to-moderate aortic stenosis (AS) at the time of coronary artery bypass graft (CABG) is controversial. Here we perform a systematic review and meta-analysis of CABG and aortic valve replacement (AVR) versus CABG alone in patients with mild-moderate AS.

METHODS

We searched MEDLINE and EMBASE databases until July 2018 for studies comparing CABG & AVR versus CABG in patients with mild-moderate AS undergoing coronary bypass. Data were extracted by 2 independent investigators. The main outcomes were operative mortality, long-term survival, and reintervention for AS.

RESULTS

There were 6 unmatched retrospective observational studies with 1,172 patients (median follow-up 4.7 [interquartile range: 4.3 to 5.3] years). Patients undergoing CABG & AVR had less severe coronary artery disease. There were no differences in operative mortality (relative risk [RR]: 1.07; 95% CI, 0.59 to 1.94; P = 0.8). CABG & AVR was associated with greater incidence of stroke, bleeding, renal failure, and mediastinitis. At median follow-up of 5 years, there was no difference in long-term mortality (incidence rate ratio [IRR]:1.44; 95% CI, 0.83 to 2.51; P = 0.19), but CABG & AVR was associated with 73% lower risk of reoperation for AS (n = 13/485 versus n = 71/702; IRR: 0.27; 95% CI, 0.14 to 0.51; P < 0.001).

CONCLUSIONS

In patients undergoing CABG with mild-moderate AS, combining AVR with CABG was associated with no difference in operative mortality but with increased risk of stroke, bleeding, renal failure, and mediastinitis. Long-term mortality was not different, but a risk of reoperation for AS at 5 years was 73% lower. Given the increasingly wide availability and safety of transcatheter aortic valve replacement (TAVR), one may consider a conservative approach toward concomitant mild-moderate AS.

Ministernotomy aortic valve surgery in patients with prior patent mammary artery grafts after coronary artery bypass grafting

OBJECTIVES

Patients with patent internal thoracic artery (ITA) grafts after prior coronary artery bypass grafting surgery who require aortic valve replacement (AVR) pose unique technical challenges for safe and optimal myocardial protection. The purpose of this study is to review our short- and long-term outcomes with redo minimally invasive AVR in patients with patent in situ ITA grafts.

METHODS

From 2008 to 2016, 48 patients with at least 1 patent in situ mammary artery graft underwent minimally invasive AVR. Preoperative computed tomography was performed in all patients to evaluate the relationship of patent grafts to the sternum. Retrograde coronary sinus and pulmonary vent catheters were placed via the right internal jugular vein. The in situ ITA grafts were not clamped during AVR. Transverse aortotomy, taking care to avoid the grafts arising from the aorta, was performed to expose the aortic valve.

RESULTS

The median age of the patients was 78 years [Quartile 1 (Q1)-Quartile 3 (Q3): 71-81]. Thirty-nine (81%) patients were men, and 46 (96%) patients had aortic stenosis. The median cardiopulmonary bypass and cross-clamp times were 124 (Q1-Q3: 108-164) and 92 (Q1-Q3: 83-116) min, respectively. Moderate hypothermia at 28-30°C was used in all patients. Most patients received cold blood cardioplegia with antegrade induction and continuous retrograde delivery. Four patients received only retrograde delivery due to some degree of aortic insufficiency. Thirty-day mortality was 4% (2 of 48 patients). There was no conversion to full sternotomy, and no reoperations were performed for postoperative bleeding or sternal wound infection. Excluding the 2 patients who died in the hospital, the median postoperative length of stay was 7 days (Q1-Q3: 5-8). Overall survival at 1, 5 and 10 years was 94%, 87% and 44%, respectively.

CONCLUSIONS

Percutaneous retrograde cardioplegia combined with antegrade cardioplegia and moderate hypothermia, without interruption of ITA flow, is a safe and reliable strategy in patients with patent ITA grafts undergoing aortic valve replacement. This strategy combined with a minimally invasive approach may reduce surgical trauma, and is a safe and effective technique in these challenging patients.

Propensity matched comparison of in-hospital outcomes of TAVR vs. SAVR in patients with previous history of CABG: Insights from the Nationwide inpatient sample

BACKGROUND

The incidence of patients with previous history of coronary artery bypass grafting (CABG) presenting for aortic valvular replacement has been consistently on the rise. Repeat sternotomy for surgical aortic valve replacement (SAVR) carries an inherent risk of morbidity and mortality when compared to Transcatheter aortic valve replacement (TAVR).

METHODS

The Nationwide inpatient sample (NIS) from 2012 to 2014 was queried using the International Classification of Diseases-Ninth edition, Clinical Modification (ICD-9-CM) codes to identify all patients ≥ 18 years with prior CABG who underwent TAVR (35.05 and 35.06) or SAVR (35.21 and 35.22). Propensity score matching (1:1) was performed and in-hospital outcomes were compared between matched cohorts.

RESULTS

From 2012 to 2014, there was progressive increase in the annual number of TAVR procedures from 1485 to 4020, with a decrease in patients undergoing SAVR from 2330 to 1955 (P_trend  < 0.0001) in the above population. There was no significant difference in in-hospital mortality rates. Compared to SAVR, TAVR was associated with lower risk of stroke (1.2% vs. 3.3%, P = 0.009), AKI (12.9% vs. 21.3%, P < 0.0001), myocardial infarction (0.9% vs. 2.7%, P = 0.01) and major bleeding (9.1% vs. 25.1%, P < 0.0001). TAVR was associated with higher risk of pacemaker implants (9.6% vs. 4.9%, P = 0.001) and trend toward lower risk of vascular complications (2.3% vs. 4.1%, P = 0.05).

CONCLUSION

In this large cohort of patients with previous CABG, there is no significant difference in in-hospital mortality between TAVR and SAVR. TAVR was associated with lower risk of in-hospital outcomes.

Transcatheter versus Surgical Aortic Valve Replacement after Previous Cardiac Surgery: A Systematic Review and Meta-Analysis

Aim

Aortic valve replacement (AVR) in patients with prior cardiac surgery might be challenging. Transcatheter aortic valve replacement (TAVR) offers a promising alternative in such patients. We therefore aimed at comparing the outcomes of patients with aortic valve diseases undergoing TAVR versus those undergoing surgical AVR (SAVR) after previous cardiac surgery.

Methods and Results

MEDLINE, EMBASE, and the Cochrane Central Register were searched. Seven relevant studies were identified, published between 01/2011 and 12/2015, enrolling a total of 1148 patients with prior cardiac surgery (97.6% prior CABG): 49.2% underwent TAVR, whereas 50.8% underwent SAVR. Incidence of stroke (3.8 versus 7.9%, p=0.04) and major bleeding (8.3 versus 15.3%, p=0.04) was significantly lower in the TAVR group. Incidence of mild/severe paravalvular leakage (14.4/10.9 versus 0%, p < 0.0001) and pacemaker implantation (11.3 versus 3.9%, p=0.01) was significantly higher in the TAVR group. There were no significant differences in the incidence of acute kidney injury (9.7 versus 8.7%, p=0.99), major adverse cardiovascular events (8.7 versus 12.3%, p=0.21), 30-day mortality (5.1 versus 5.5%, p=0.7), or 1-year mortality (11.6 versus 11.8%, p=0.97) between the TAVR and SAVR group.

Conclusions

TAVR as a redo procedure offers a safe alternative for patients presenting with aortic valve diseases after previous cardiac surgery especially those with prior CABG.

Transcatheter Aortic Valve Replacement After Coronary Artery Bypass Graft Is Associated With Increased Pacemaker Implantation but Not Reduced Overall Survival

Background

A history of coronary artery bypass graft (CABG) is a common compelling indication for transcatheter aortic valve replacement (TAVR). However, there is little data on how these patients compare to other TAVR patients. In this study, the short and long-term outcomes of these TAVR patients after CABG are defined.

Methods

A retrospective chart review case-control study of 337 consecutive patients who underwent a TAVR for severe aortic stenosis at Sanford Health in Fargo ND was performed to determine if a history of prior CABG was associated with worse outcomes after TAVR as compared to a TAVR cohort without a history of CABG.

Results

Despite higher predicted surgical risk, patients with a history of CABG had no significant difference overall survival at 1 month (98% vs. 93%, P = 0.112), 6 months (94% vs. 87%, P = 0.094), 1 year (85% vs. 77%, P = 0.206) or 2 years (70% vs. 57%, P = 0.135) post-TAVR. However, a history of CABG was associated with an increase in post-TAVR permanent pacemaker (PPM) implantation (15% vs. 6%, P = 0.015).

Conclusions

This study gives evidence to suggest that patients with a history of prior CABG do not have any difference in overall survival as other TAVR patients, despite higher predicted surgical risk and differences in preprocedural comorbidities. Our study also confirms the safety of TAVR in this specific population in lower volume centers.

Parsimonious assessment for reoperative aortic valve replacement; the deterrent effect of low left ventricular ejection fraction and renal impairment

BACKGROUND

Patient comorbidities play a pivotal role in the surgical outcomes of reoperative aortic valve replacement (re-AVR). Low left ventricular ejection fraction (LVEF) and renal insufficiency (Cr >2 mg/dL) are known independent surgical risk factors. Improved preoperative risk assessment can help determine the best therapeutic approach. We hypothesize that re-AVR patients with low LVEF and concomitant renal insufficiency have a prohibitive surgical risk and may benefit from transcatheter AVR (TAVR).

METHODS

From January 2002 to March 2013, we reviewed 232 patients who underwent isolated re-AVR. Patients older than 80 years were excluded to adjust for unobserved frailty. We identified 37 patients with a ≤35% LVEF (low ejection fraction group-LEF) and 195 patients with >35% LVEF (High ejection fraction group-HEF).

RESULTS

The mean age was 68.4±11.5 years and there were more females (86.5% versus 64.1%, P=0.007) in the LEF group. The prevalence of renal insufficiency was higher in LEF patients (27% versus 5.6%, P=0.001). Higher operative mortality (13.5% versus 3.1%, P=0.018) was observed in the LEF group. Stroke rates were similar in both groups (8.1% versus 4.1%, P=0.39). Unadjusted cumulative survival was significantly lower in LEF patients (6.6 years, 95% CI: 5.2-8.0, versus 9.7 years, 95% CI: 8.9-10.4, P=0.024). In patients without renal insufficiency, LEF and HEF had similar survival (8.3 years, 95% CI: 7.1-9.5, versus 9.9 years, 95% CI: 9.1-10.6, P=0.90). Contrarily, in patients with renal insufficiency, LEF led to a significantly lower survival (1.1 years, 95% CI: 0.1-2.0, versus 4.8 years, 95% CI: 2.2-7.3, P=0.050). Adjusted survival analysis revealed elevations in baseline creatinine (HR =4.28, P<0.001) and LEF (HR =5.33, P=0.041) as significant predictors of long-term survival, with a significant interaction between these comorbidities (HR =7.28, P<0.001).

CONCLUSIONS

In re-AVR patients, low LVEF (≤35%) is associated with increased operative mortality. Concomitant renal insufficiency in these patients results in a prohibitively low cumulative survival. These reoperative surgical outcomes should warrant expanding the role of TAVR for reoperative patients with LEF and renal impairment.

Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies

OBJECTIVE

 To determine the frequency of survival, stroke, atrial fibrillation, structural valve deterioration, and length of hospital stay after surgical replacement of an aortic valve (SAVR) with a bioprosthetic valve in patients with severe symptomatic aortic stenosis.

DESIGN

 Systematic review and meta-analysis of observational studies.

DATA SOURCES

 Medline, Embase, PubMed (non-Medline records only), Cochrane Database of Systematic Reviews, and Cochrane CENTRAL from 2002 to June 2016.

STUDY SELECTION

 Eligible observational studies followed patients after SAVR with a bioprosthetic valve for at least two years.

METHODS

 Reviewers, independently and in duplicate, evaluated study eligibility, extracted data, and assessed risk of bias for patient important outcomes. We used the GRADE system to quantify absolute effects and quality of evidence. Published survival curves provided data for survival and freedom from structural valve deterioration, and random effect models provided the framework for estimates of pooled incidence rates of stroke, atrial fibrillation, and length of hospital stay.

RESULTS

 In patients undergoing SAVR with a bioprosthetic valve, median survival was 16 years in those aged 65 or less, 12 years in those aged 65 to 75, seven years in those aged 75 to 85, and six years in those aged more than 85. The incidence rate of stroke was 0.25 per 100 patient years (95% confidence interval 0.06 to 0.54) and atrial fibrillation 2.90 per 100 patient years (1.78 to 4.79). Post-SAVR, freedom from structural valve deterioration was 94.0% at 10 years, 81.7% at 15 years, and 52% at 20 years, and mean length of hospital stay was 12 days (95% confidence interval 9 to 15).

CONCLUSION

 Patients with severe symptomatic aortic stenosis undergoing SAVR with a bioprosthetic valve can expect only slightly lower survival than those without aortic stenosis, and a low incidence of stroke and, up to 10 years, of structural valve deterioration. The rate of deterioration increases rapidly after 10 years, and particularly after 15 years.

Transcatheter aortic valve replacement versus surgical aortic valve replacement in patients with previous coronary artery bypass surgery: A systematic review and meta-analysis

BACKGROUND

Patients with severe aortic stenosis (AS) and previous coronary artery bypass graft (CABG) surgery have increased risk for aortic valve replacement. Whether surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) offers better outcomes in this population is unclear. We aimed to assess outcomes of TAVR and SAVR in patients with previous CABG.

METHODS

A systematic literature search of Medline, EMBASE and Cochrane library was conducted. Studies that reported clinical outcomes (perioperative or mid-term all-cause-mortality, cardiovascular mortality, pacemaker implantation, hospital duration and stroke) were included. Random-effect modeling was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Five cohort studies including a total of 872 patients (423 in TAVR, 449 in SAVR) were analyzed. STS scores were comparable between the two groups. No difference in all-cause-mortality, cardiovascular mortality and stroke at 30days, 1year and total follow-up period was seen between the two groups. TAVR patients had higher pacemaker implantation rates (OR 3.41, 95% CI 1.66-6.38, p<0.001, I(2)=21%) and shorter hospital stay (-2.63days, 95% CI -5.20 to -0.04, p=0.05, I(2)=43%).

CONCLUSIONS

Patients with previous CABG who underwent TAVR had similar perioperative and long-term survival while experiencing more pacemaker implantations and shorter hospital stay compared to those who had SAVR making TAVR a safe and efficacious alternative to SAVR.

Results of surgical aortic valve replacement and transapical transcatheter aortic valve replacement in patients with previous coronary artery bypass grafting

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.

Transcatheter or Surgical Aortic Valve Replacement in Patients With Prior Coronary Artery Bypass Grafting

BACKGROUND

Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are treatment options for aortic stenosis in patients with prior coronary artery bypass graft surgery. We assessed the major clinical outcomes of such patients enrolled in the CoreValve High Risk (CHR) study.

METHODS

Of the 795 CHR study patients, 226 had prior coronary artery bypass graft surgery; 115 underwent TAVR and 111 underwent SAVR. The primary endpoint was a comparison of all-cause mortality at 1 year. Important secondary clinical endpoints were assessed.

RESULTS

At 1 year, all-cause mortality was 9.6% for TAVR versus 18.1% for SAVR (p = 0.06); cardiovascular mortality was 7.0% for TAVR versus 13.8% for SAVR (p = 0.09). A combination of The Society of Thoracic Surgeons risk score greater than 7 and age greater than 80 years was a significant predictor of mortality, with TAVR demonstrating a survival advantage (p = 0.03). No differences were seen for stroke. The SAVR group had longer intensive care unit and hospital stays, increased incidence of acute kidney injury, life-threatening or disabling bleeding, and major adverse cardiac and cerebrovascular events (p < 0.05). Pacemaker implantation and paravalvular regurgitation were greater with TAVR at all timepoints.

CONCLUSIONS

For patients with prior coronary artery bypass graft surgery and aortic stenosis, TAVR offers a significant morbidity advantage and a strong trend toward improved survival over SAVR at 1 year.