Objectives

The aim of this study was to compare, in a cohort of patients with complex coronary artery disease (CAD) and severe aortic stenosis (AS), the clinical outcomes associated with transfemoral transcatheter aortic valve replacement (TAVR) (plus percutaneous coronary intervention [PCI]) versus surgical aortic valve replacement (SAVR) (plus coronary artery bypass grafting [CABG]).

Background

Patients with complex CAD were excluded from the main randomized trials comparing TAVR with SAVR, and no data exist comparing TAVR + PCI vs SAVR + CABG in such patients.

Methods

A multicenter study was conducted including consecutive patients with severe AS and complex CAD (SYNTAX [Synergy Between PCI with Taxus and Cardiac Surgery] score >22 or unprotected left main disease). A 1:1 propensity-matched analysis was performed to account for unbalanced covariates. The rates of major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, nonprocedural myocardial infarction, need for new coronary revascularization, and stroke, were evaluated.

Results

A total of 800 patients (598 undergoing SAVR + CABG and 202 undergoing transfemoral TAVR + PCI) were included, and after propensity matching, a total of 156 pairs of patients were generated. After a median follow-up period of 3 years (interquartile range: 1-6 years), there were no significant differences between groups for MACCE (HR for transfemoral TAVR vs SAVR: 1.33; 95% CI: 0.89-1.98), all-cause mortality (HR: 1.25; 95% CI: 0.81-1.94), myocardial infarction (HR: 1.16; 95% CI: 0.41-3.27), and stroke (HR: 0.42; 95% CI: 0.13-1.32), but there was a higher rate of new coronary revascularization in the TAVR + PCI group (HR: 5.38; 95% CI: 1.73-16.7).

Conclusions

In patients with severe AS and complex CAD, TAVR + PCI and SAVR + CABG were associated with similar rates of MACCE after a median follow-up period of 3 years, but TAVR + PCI recipients exhibited a higher risk for repeat coronary revascularization. Future trials are warranted.

中文翻译：

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复杂冠状动脉疾病患者的经导管与外科主动脉瓣置换术

目标

本研究的目的是在一组患有复杂冠状动脉疾病 (CAD) 和严重主动脉瓣狭窄 (AS) 的患者中，比较与经股经导管主动脉瓣置换术 (TAVR)（加经皮冠状动脉介入治疗 [PCI ]）与外科主动脉瓣置换术（SAVR）（加上冠状动脉旁路移植术[CABG]）。

背景

复杂 CAD 患者被排除在比较 TAVR 与 SAVR 的主要随机试验之外，并且没有在此类患者中比较 TAVR + PCI 与 SAVR + CABG 的数据。

方法

进行了一项多中心研究，包括连续患有严重 AS 和复杂 CAD 的患者（SYNTAX [PCI 与红豆杉和心脏手术之间的协同作用] 评分 >22 或无保护的左主干病变）。进行了 1:1 的倾向匹配分析以解释不平衡的协变量。评估了主要不良心脑血管事件（MACCE）的发生率，包括全因死亡率、非手术性心肌梗死、需要新冠脉血运重建和卒中。

结果

共纳入 800 例患者（598 例接受 SAVR+CABG，202 例接受经股动脉 TAVR+PCI），经倾向匹配后，共生成 156 对患者。中位随访 3 年（四分位距：1-6 年）后，MACCE 组之间没有显着差异（经股动脉 TAVR 与 SAVR 的 HR：1.33；95% CI：0.89-1.98），所有-导致死亡率（HR：1.25；95% CI：0.81-1.94）、心肌梗塞（HR：1.16；95% CI：0.41-3.27）和中风（HR：0.42；95% CI：0.13-1.32），但有TAVR + PCI 组的新冠脉血运重建率更高（HR：5.38；95% CI：1.73-16.7）。

结论

在严重 AS 和复杂 CAD 患者中，TAVR + PCI 和 SAVR + CABG 在中位随访 3 年后与相似的 MACCE 发生率相关，但 TAVR + PCI 受者表现出更高的重复冠状动脉血运重建风险。未来的试验是必要的。