ORLANDO, FL—Transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) produces comparable results to surgery in patients with aortic stenosis and concomitant coronary artery disease (CAD), according to results presented November 15, 2011, at the American Heart Association Scientific Sessions.

With surgery as the current standard of care for these characteristic high-risk patients, Daniel Wendt, MD, of the West German Heart Center (Essen, Germany), said CAD is known to preexist in about 25% of patients, although recent reports have stated figures as high as 56%.

Dr. Wendt and colleagues enrolled 243 consecutive high-risk patients (STS score > 10% and/or EuroSCORE > 15%) presenting with aortic stenosis and concomitant CAD to a nonrandomized, single-center study. Patients were treated either by surgical aortic valve replacement plus CABG (n = 184) or by transapical or transfemoral TAVR plus PCI performed within the prior 12 months (n = 59).

Transcatheter Patients at Higher Risk

Disease severity was greater in the TAVR arm, which could be attributed to significant differences in age, LVEF, NYHA class, peripheral vascular disease, STS score, and EuroSCORE between the 2 arms.

The primary endpoint of 30-day mortality was reported in 12.5% of patients in the surgery arm and in 11.9% of patients in the TAVR arm (OR 0.94; 95% CI 0.38-2.32; P = 0.89).

Univariate analysis identified LVEF, pulmonary hypertension, renal insufficiency, STS score, EuroSCORE, and previous cardiac surgery (P < 0.05 for all) as predictors of mortality. On subsequent risk-adjusted analysis, only LVEF remained a significant predictor of mortality. Assignment to surgery or TAVR was not associated with the primary endpoint.

When groups were further adjusted with propensity matching, mortality equivalence between the two arms was confirmed.

Relieving Symptoms with TAVR

Dr. Wendt noted the study’s limitations of being single-center, small, and retrospective with varying risk-scores between groups. “Both groups showed comparable in-hospital mortality, despite differences between groups,” he said. “Whether there is an advantage of one approach over the other remains to be elucidated. It should be emphasized, however, that to date, surgical [valve replacement] with combined CABG remains the standard therapy.”

Audience member Robert A. Guyton, MD, of Emory University (Atlanta, GA), commented, “My surprise is that the TAVI group was not significantly better than the surgical group—because we, as surgeons, really don’t like to operate on an 85-year old patient with combined aortic disease and CAD. Increasingly, we are working very hard to get the vessel stented prior to surgery and then doing a very small, minimally invasive AVR rather than a standard procedure.”

He added that, “With 75- to 80–year-old patients, we’re generally operating for relief of symptoms, not for prolongation of life. If somebody has a Syntax score of 30, then the thing to do might be to stent the vessels and then see if they still have symptoms. If they don’t, maybe they don’t need either procedure. You’ve got to take each patient individually.”

Study Details

For TAVR, the transfemoral approach was used in 64.4% of procedures and the transapical in 35.6%. Surgeries had a mean of 2.1 distal anastomoses, and in the TAVR group a mean of 1.6 lesions were treated (P < 0.001) per patient. BMS and DES were implanted in 69.5% and 30.5% of patients, respectively, in TAVR patients.

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