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Brief Report
June 19, 2019

Comparison of Outcomes After Transcatheter vs Surgical Aortic Valve Replacement Among Patients at Intermediate Operative Risk With a History of Coronary Artery Bypass Graft Surgery: A Post Hoc Analysis of the SURTAVI Randomized Clinical Trial

Author Affiliations
  • 1Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
  • 2St Antonius Hospital, Nieuwegein, the Netherlands
  • 3Erasmus University Medical Center, Rotterdam, the Netherlands
  • 4NYU Langone Medical Center, New York, New York
  • 5OhioHeath Riverside Methodist Hospital, Columbus, Ohio
  • 6The Johns Hopkins University, Baltimore, Maryland
  • 7Iowa Heart Center, Des Moines
  • 8St Francis Hospital, Roslyn, New York
  • 9Medtronic, Minneapolis, Minnesota
  • 10Beth Israel Deaconess Medical Center, Boston, Massachusetts
JAMA Cardiol. 2019;4(8):810-814. doi:10.1001/jamacardio.2019.1856
Key Points

Question  Is there evidence to guide the treatment decision between transcatheter or surgical aortic valve replacement for patients with aortic stenosis at intermediate operative risk and a history of coronary artery bypass graft (CABG) surgery?

Findings  In this post hoc analysis of 273 intermediate-risk patients with prior CABG surgery enrolled in a randomized clinical trial, both transcatheter and surgical aortic valve replacement were safe and provided symptom relief. The transcatheter approach provided more rapid improvement in quality of life and better exercise tolerance at 1-year follow-up.

Meaning  Transcatheter and surgical aortic valve replacement are appropriate treatments in patients with prior CABG surgery, and the less-invasive transcatheter approach may facilitate faster recovery.

Abstract

Importance  Surgical aortic valve replacement (SAVR) has increased risk for patients with aortic stenosis (AS) and a history of coronary artery bypass graft (CABG) surgery. Transcatheter aortic valve replacement (TAVR) may be an alternative.

Objective  To compare TAVR with SAVR outcomes in patients at intermediate operative risk with prior CABG surgery.

Design, Setting, and Participants  In this post hoc analysis of the Surgical Replacement and Transcatheter Aortic Valve Implantation (SURTAVI) noninferiority randomized clinical trial, patients with severe, symptomatic AS at intermediate operative risk were enrolled from 87 centers across the United States, Europe, and Canada from June 2012 to June 2016 and followed-up with up to July 2017. Those with a history of CABG surgery were considered for analysis. Data were analyzed from September to December 2017.

Interventions  A total of 1746 patients were enrolled and randomized 1:1 to self-expanding TAVR or SAVR. An implant was attempted in 1660 patients, of whom 273 had prior CABG surgery, including 136 who underwent attempted TAVR and 137 who underwent attempted SAVR.

Main Outcomes and Measures  The primary outcome was all-cause mortality or disabling stroke at 1-year follow-up. Efficacy outcomes included quality of life, measured using the Kansas City Cardiomyopathy Questionnaire at 30 days, 6 months, and 1 year, and distance walked in 6 minutes, measured using the 6-minute walk test at 30 days and 1 year.

Results  Of the 136 patients in the TAVR cohort, 111 (81.6%) were male, and the mean (SD) age was 76.9 (6.5) years; of the 137 in the SAVR cohort, 117 (85.4%) were male, and the mean (SD) age was 76.6 (6.5) years. The mean (SD) Society of Thoracic Surgeons Predicted Risk of Mortality score was 5.0% (1.6%) in the TAVR cohort and 5.2% (1.7%) in the SAVR cohort. All-cause mortality or disabling stroke at 1-year follow-up was 8.9% (95% CI, 5.2-15.2) in the TAVR cohort and 6.7% (95% CI, 3.5-12.8) in the SAVR cohort (log-rank P = .53). Compared with patients receiving SAVR, the mean (SD) Kansas City Cardiomyopathy Questionnaire summary score was significantly better among patients receiving TAVR at 30 days (81.4 [19.2] vs 69.7 [22.6]; P < .001); treatments were similar at 1 year (85.7 [14.6] vs 82.8 [18.4]; P = .19). Compared with patients in the SAVR cohort, those in the TAVR cohort showed greater mean (SD) improvement in distance walked at 1 year (48.3 [120.6] m vs 16.8 [88.7] m; P = .04).

Conclusions and Relevance  Both TAVR and SAVR were safe for intermediate-risk patients with AS and prior CABG surgery. The transcatheter approach facilitated faster improvement in quality of life and better exercise capacity at 1-year follow-up.

Trial Registration  ClinicalTrials.gov identifier: NCT01586910

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