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Combined Cath Approach No Match for Surgery for Aortic Stenosis, CAD

— Pacemakers increasingly an issue in TAVR plus PCI

Last Updated February 1, 2021
MedpageToday

The percutaneous-only approach to aortic stenosis and coronary artery disease (CAD) left patients with higher rates of cardiac and vascular complications compared with surgery, researchers reported.

Data from the National Inpatient Sample (NIS) showed that in-hospital mortality in 2012-2017 reached 5.1% after transcatheter aortic valve replacement (TAVR) plus percutaneous coronary intervention (PCI), which was not significantly higher than the 3.5% after surgical aortic valve replacement (SAVR) plus coronary artery bypass grafting (CABG; adjusted OR 1.09, 95% CI 0.95-1.26).

Even so, complication rates favored SAVR plus CABG over the combined transcatheter approach when it came to pacemaker implants, cardiac arrest, and vascular complications, reported Sri Patlolla, MBBS, of the Mayo Clinic in Rochester, Minnesota, at the Society of Thoracic Surgeons (STS) virtual meeting.

On the other hand, TAVR plus PCI was associated with less hemodialysis and prolonged ventilation. Stroke was comparable between groups.

Patlolla reminded attendees that 60% of patients receiving aortic valve interventions have CAD, and that guidelines recommend concomitant CABG to avoid the risk of repeat sternotomy.

Notably, NIS data showed that the proportion of people getting TAVR plus PCI increased from 1.1% in 2012 to 9.6% in 2017, with corresponding losses in SAVR plus CABG.

The good news for the transcatheter approach was that mortality fell from more than 16% to below 4% over the same period (P<0.001). However, the rise of pacemaker implants after TAVR plus PCI was a worrying trend (4.8% in 2012 to 13.5% in 2017).

Study findings confirm that the transcatheter field is improving rapidly whereas surgery is already a mature procedure, commented STS discussant Michael Reardon, MD, of Houston Methodist DeBakey Heart & Vascular Center.

What's more, the study ended in 2017, when TAVR was still being performed in higher-risk patients who may not be comparable to peers getting surgery. Since TAVR's FDA approval for low-risk patients in 2019, young patients are increasingly opting for TAVR in contemporary practice.

Randomized data stratified by the two combined approaches are scare but do exist, Reardon said, citing as one example showing the transcatheter method to be a reasonable alternative to surgery.

In the present study, participants were split between the combined surgical group (n=106,510) and the transcatheter group (n=4,850). Patlolla's group excluded people with other concomitant major cardiac procedures and those getting CABG and PCI during the same hospitalization.

Compared with those receiving the combined percutaneous treatment, the surgical cohort was significantly younger (mean 72.7 vs 80.5), more likely to be male (72.7% vs 53.0%), and had a lower comorbidity index score (4.8 vs 6.6).

Compared with their surgical peers, the transcatheter cohort was significantly more likely to be discharged home. These patients also had shorter lengths of hospital stay (7 vs 8 days) but consistently higher hospitalization costs (median $272,000 vs $175,000).

Stratifying patients by how their dual procedures were staged, Patlolla reported that the 145 people who received PCI after TAVR had especially high complication rates (24.1% mortality, 10.3% vascular complications, 3.4% stroke).

Yet it was the 1,665 people with PCI staged before TAVR that had the highest pacemaker rate, at 12%.

The authors acknowledged that their analysis relied on the NIS data being accurate. Moreover, the dataset lacked information on CAD severity or important procedural characteristics such as type of valve, the group cautioned.

Thus, the investigators attempted to adjust for differences between surgical and percutaneous groups but left room for bias and confounding; a center's heart team would have decided what is the best therapy for a patient with aortic stenosis and CAD, and adjusting for such judgment is difficult if not impossible, Reardon said.

Reardon's suggestion to perform propensity score matching would require more granular data than what was at hand, Patlolla said.

Disclosures

Patlolla disclosed no relevant relationships with industry.

Primary Source

Society of Thoracic Surgeons

Patlolla SH, et al "Management of aortic stenosis and coronary artery disease: increased risk of complications and higher hospitalization cost of transcatheter versus surgical approaches" STS 2021.