Outcomes in Patients With Severe Coronary Artery Disease and Aortic Stenosis Undergoing Surgical Aortic Valve Replacement and Coronary Artery Bypass Grafting vs. Transcatheter Aortic Valve Replacement

Background: Coronary artery disease (CAD) is highly prevalent in veterans with severe aortic stenosis (AS). However, the optimal management of CAD in this patient population remains a topic of contention. Historical management was predicated on surgical aortic valve replacement (SAVR) with concomitant coronary artery bypass grafting (CABG). Transcatheter aortic valve replacement (TAVR) has demonstrated efficacy in managing aortic stenosis in this population, albeit without addressing the underlying CAD when performed in isolation. This has resulted in a debate regarding the management of CAD in the context of severe AS, which requires intervention. This manuscript aimed to provide evidence to assist physicians in choosing the optimal management of patients presenting with severe AS and CAD. Methods: This is a retrospective cohort study using the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database. Perioperative data were extracted for patients with severe AS and high-grade (≥70%) left anterior descending (LAD) artery stenosis who underwent either SAVR + CABG or isolated TAVR between 2012 and 2020. Cohorts were propensity matched. The odds of myocardial infarction (MI) and stroke within 30 days of surgery were compared using logistic regression. The survival probability at 1 month, 6 months, 2 years, and 5 years was compared using a time-varying Cox regression. Results: A total of 587 patients were included (332 SAVR + CABG and 255 isolated TAVR). Propensity score matched (PSM) analysis alongside the nearest-neighbor method yielded a paired sample of 510 patients. MI was not observed within 30 days postoperatively for either group. The TAVR cohort had 92% lower odds of postoperative stroke (odds ratio (OR) = 0.08; 95% confidence interval (CI) [0.00, 0.50]; p = 0.027). No significant differences were observed in survival within the first 30 days. Between one and six months post-operation, the TAVR cohort had higher survival than the SAVR + CABG cohort (hazard ratio (HR) = 0.38; 95% CI [0.15, 0.95]; p = 0.038). However, between 2 and 5 years, the TAVR cohort exhibited a lower survival (HR = 1.69; 95% CI [1.05, 2.70]; p = 0.030). Overall, the TAVR cohort had a lower 5-year survival rate. Conclusions: Although SAVR + CABG may increase the risk of postoperative stroke, this combination is associated with improved long-term mortality in patients with severe AS and severe CAD. Furthermore, the need for additional revascularization is reduced in patients undergoing SAVR + CABG, including those with single-vessel CAD. In contrast, TAVR reduces 30-day stroke risk but does not demonstrate the same mortality benefit long-term when compared to SAVR + CABG.