12 Transcatheter versus surgical approach for severe aortic stenosis with concomitant coronary artery disease: a systematic review and meta-analysis of early and mid-term outcomes

Abstract

Introduction Coronary artery disease (CAD) is frequently encountered in patients undergoing transcatheter aortic valve replacement (TAVR). Contemporary recommendations advocate revascularisation of patients with severe aortic stenosis (AS) and concomitant significant coronary artery disease (CAD) by either a surgical or percutaneous approach. We undertook a systematic review and meta-analysis to evaluate the early and mid-term outcomes of patients who underwent surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) against patients who had TAVR and percutaneous coronary intervention (PCI). Methods A search of Medline and Embase was performed to identify studies comparing transcatheter and surgical approaches. Our search was independently screened by two investigators. Random effects meta-analyses with the Mantel-Haenzsel method were performed to estimate the odds of adverse outcomes. Analyses were performed with RevMan (Review Manager version 5.3.5, Nordic Cochrane Centre, Denmark). Results 1770 participants from six studies (5 observational, 1 randomised) were included in the meta-analysis (631 TAVR and PCI, 1139 SAVR and CABG). The mean age of participants was 79.2 years and 58.9% were male. TAVR was performed via both transapical/transaortic and transfemoral routes, using both self-expandable and balloon expandable valve systems. PCI was conducted either concomitant to TAVR or up to a year before. Risk of bias assessed using the ROBINS-I tool, identified 1 study at low risk and 4 studies at high risk of bias, predominately due to selection bias. There were no significant differences in effect estimates for early and mid-term mortality (OR: 0.78; 95% CI, 0.50-1.20 and OR: 1.09; 95% CI, 0.80-1.49) or myocardial infarction (OR: 0.52 95% CI, 0.20-1.33 and OR: 1.34; 95% CI, 0.67-2.65) No significant difference was noted in early cerebrovascular accidents (OR: 0.80; 95% CI, 0.35-1.87). A transcatheter approach was associated with a higher rate of new permanent pacemaker insertion (OR: 3.47; 95% CI, 1.98-6.06) and major vascular complications (OR: 14.44; 95% CI, 4.42-47.16), but a lower rate of acute kidney injury (OR: 0.41; 95% CI, 0.19-0.91). Conclusion These data suggest that in patients with severe AS and CAD a transcatheter approach has comparable outcomes to a surgical approach. Pending high level evidence, surgical risk assessment should form the cornerstone of individualised decision making. Conflict of Interest None