CABG plus surgical AVR may suit certain older patients with aortic stenosis, CAD

Key takeaways:

• CABG/surgical AVR was tied to lower risk for stroke, MI, valve reintervention or death vs. PCI/TAVR for aortic stenosis and CAD.
• PCI/TAVR was tied to lower odds of bleeding, kidney injury and in-hospital death.

CABG plus surgical aortic valve replacement for treatment of coronary disease and aortic stenosis was associated with better 5-year outcomes vs. PCI plus transcatheter aortic valve replacement in Medicare beneficiaries, a speaker reported.

This study using real-word data was presented at the Society of Thoracic Surgeons annual meeting and simultaneously published in The Annals of Thoracic Surgery.

“This study originated as a clinical question because many times we are faced with low-risk patients who are great candidates for surgical [AVR] or TAVR but are found to have significant CAD,” J. Hunter Mehaffey, MD, MSc, assistant professor and director of cardiac surgery research in the department of cardiovascular and thoracic surgery at West Virginia University, told Healio. “Our heart team frequently discusses if a surgical approach with CABG is preferred or if these patients should get a transcatheter approach with PCI despite their low risk and frequent younger age — less than 85 years. The TCW trial was very small — less than 100 patients per arm — with an operative mortality of nearly 10% with CABG/AVR, so we sought to evaluate real-world data in the largest longitudinal dataset available — Medicare.”

Using the CMS inpatient claims databases, Mehaffey and colleagues evaluated real-world outcomes among 37,822 older patients with CAD on admission who underwent CABG and tissue valve surgical AVR compared with PCI/TAVR (simultaneously or within 3 months) between 2018 and 2022.

People with a history of cardiac surgery, TAVR, coronary revascularization for STEMI, emergent admission, pure aortic insufficiency or endocarditis were excluded from the study.

The primary outcome was a composite of stroke, MI, valve reintervention or death.

Baseline characteristics and comorbidities were well balanced between the CABG/AVR and PCI/TAVR groups, according to the study.

The researchers reported that, compared with CABG/AVR, PCI/TAVR at index admission was associated with lower odds of major bleeding (OR = 0.72; P < .0001), acute kidney injury (OR = 0.25; P < .0001) and in-hospital mortality (OR = 0.43; P < .0001); no significant difference in odds of stroke (OR = 1; P = .975); and higher odds of new pacemaker (OR = 1.59; P < .0001) and femoral artery surgical repair (OR = 7.1, P < .0001).

“Not surprisingly, we see PCI/TAVR was associated with lower periprocedural mortality, acute kidney injury and major bleeding but with higher need for new pacemaker and vascular complications,” Mehaffey told Healio. “However, the longitudinal analysis tells a very different story.”

In the researchers’ risk-adjusted 5-year longitudinal analysis, PCI/TAVR was associated with greater risk for stroke readmission (HR = 1.1; P = .024), MI (HR = 1.68; P < .0001), all-cause mortality (HR = 1.09; P < .0001) and the composite outcome of stroke, MI, valve reintervention or death (HR = 1.26; P < .0001) compared with CABG/AVR.

“In fact, surgery was associated with lower incidence of nearly all secondary endpoints including MI, coronary reintervention, stroke and HF readmission; however, valve reintervention was very low at 5 years and not different between groups. Finally, subgroup analysis of patients requiring only single-vessel revascularization demonstrated similar findings favoring a surgical approach,” Mehaffey told Healio. “I am a huge proponent of TAVR and an active member of our structural heart team. This procedure saves lives and is an outstanding option for many patients; however, we need to continue to rely on a thoughtful heart team and seek to tailor the treatment to each patient’s specific risks and needs.”

Reference:

• Jagadeesan V, et al. Ann Thorac Surg. 2025;doi:10.1016/j.athoracsur.2024.12.016.

For more information:

J. Hunter Mehaffey, MD, MSc, can be reached at 1 Medical Center Drive, Morgantown, West Virginia 26506.