TAVI is increasingly seen as the preferred approach for aortic valve replacement in CABG patients

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Deepak L Bhatt

A review of the trends in the use and propensity-matched analysis of in-hospital outcomes, published in Circulation: Cardiovascular Interventions, indicates that the number of patients with a history of coronary artery bypass grafting (CABG) undergoing aortic valve replacement is increasing. Furthermore, transcatheter aortic valve implantation (TAVI) is increasingly being used as the preferred approach in this group.

Writing in the journal, Tanush Gupta (Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, USA) and others report that a substantial number of patients requiring aortic valve replacement have previous undergone CABG “because similar risk factors are responsible for the pathogenesis of coronary artery disease and aortic stenosis”.  They add that reoperative cardiac surgery (ie. surgical valve replacement after CABG) is associated with a greater risk of mortality and morbidity, noting that recent European valvular heart disease guidelines advise that both previous cardiac surgery and the presence of intact bypass grafts at risk of damage during redo sternotomy should be seen “as considerations for heart team decision making between TAVI and surgical aortic valve replacement”.

The aim of the present study was, therefore, to determine if the use of TAVI has increased in patients with prior history of CABG undergoing aortic valve replacement and to evaluate if it was associated with more favourable short-term outcomes than surgery. To achieve this, Gupta et al compared 2012 data from the National Inpatient Sample databases with that from 2014.

Overall, they found that the 10.2% of patients with a prior history of CABG underwent isolated aortic valve replacement between 2012 and 2014. “Of the total number of isolated aortic valve replacements, the proportion of those in patients with prior CABG increased from 9.2% to 2012 to 11.4% in 2014 (P trend <0.01),” the authors note.

Study investigator Deepak Bhatt (Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, USA) told Cardiovascular News that this increase may well relate to patients who previously would have been unable to undergo surgery—because of the risk of complications were too high—now being able to receive TAVI. He adds that this is “a great development for those types of patients”.

Of those who underwent aortic valve replacement, more patients underwent TAVI than underwent surgery (59% vs. 41%, respectively). Additionally, the proportion of surgical aortic valve replacement procedures decreased between 2012 and 2014 while the proportion of TAVI procedures increased (p trend <0.001). “In the first quarter of 2012, surgical aortic valve replacement was the predominant modality of aortic valve replacement, whereas by the fourth quarter of 2012, TAVI became the predominant modality of aortic valve replacement in patients with prior CABG, with its utilisation continuing to increase the through the last quarter of 2014,” Gupta et al comment.

Bhatt notes the preference for TAVI over surgery in this context is because the “risks of reoperative surgery are much higher than the initial surgery”. He adds: “The patients have already had a median sternotomy and are older at the time of the potential second surgery. Therefore, TAVI is increasingly preferred, and this trend will continue.”

In the study, after propensity matched scoring, the rate of in-hospital mortality was similar between TAVI and surgery patients. Furthermore, the lower incidence of myocardial infarction, stroke, bleeding, and acute kidney injury were all lower in the TAVI patients. However, the need for a permanent pacemaker was almost two-fold higher in TAVI patients (8.9% vs. 5.4%).

On the basis of these results, Bhatt comments that “in general” TAVI should be seen as the preferred approach to surgery in patients with a history of CABG. However, he comments that the results with surgical aortic valve replacement “were in fact good”. “So if a patient needs concomitant revascularisation that cannot be achieved percutaneously and if the patient is otherwise a good surgical candidate, surgical aortic valve replacement plus CABG with multivessel revascularisation might also be considered,” he says.

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