Author + information
- Tanush Gupta1,
- Sahil Khera2,
- Dhaval Kolte3,
- Kashish Goel4,
- Ankur Kalra5,
- Pedro Villablanca6,
- Herbert Aronow7,
- J. Dawn Abbott8,
- Gregg Fonarow9,
- Sammy Elmariah10,
- Chet Rihal4,
- Mario Garcia11 and
- Deepak Bhatt12
- 1Albert Einstein College of Medicine/ Montefiore Medical Center, Bronx, New York, United States
- 2Westchester Medical Center, Valhalla, New York, United States
- 3Brown University, Providence, Rhode Island, United States
- 4Mayo Clinic, Rochester, Minnesota, United States
- 5Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
- 6New York University, New York, New York, United States
- 7Lifespan Cardiovascular Inst, Providence, Rhode Island, United States
- 8Brown Medical School, Providence, Rhode Island, United States
- 9UCLA, Los Angeles, California, United States
- 10Massachusetts General Hospital, Boston, Massachusetts, United States
- 11Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, United States
- 12Brigham and Women's Hospital, Boston, Massachusetts, United States
A significant proportion of patients with aortic stenosis have undergone previous coronary artery bypass grafting (CABG). Reoperative heart surgery is associated with increased perioperative risk. We hypothesized that the adoption of transcatheter aortic valve replacement (TAVR) would have increased in patients with prior CABG undergoing aortic valve replacement (AVR) and that TAVR would be associated with more favorable short-term outcomes compared with SAVR in these patients.
We queried the 2012-2014 National Inpatient Sample databases to identify all patients aged ≥18 years with prior CABG undergoing isolated AVR (TAVR or SAVR). Patients undergoing concomitant revascularization (percutaneous coronary intervention or CABG) during the same hospitalization or with a history of prior valve surgery were excluded. Temporal trends in utilization of TAVR and SAVR were examined using the Cochrane-Armitage test. Propensity score matching was used to assemble a matched cohort of patients, who were balanced on baseline demographic, hospital, and clinical characteristics. In-hospital outcomes of TAVR vs. SAVR among matched patients were compared using bivariate logistic or linear regression models.
Of 147,395 patients undergoing isolated AVR during the study period, 15,055 (10.2%) had a history of prior CABG. The number of TAVRs in patients with prior CABG increased from 1,615 in 2012 to 4,400 in 2014, whereas the number of SAVRs decreased from 2,285 in 2012 to 1,895 in 2014 (ptrend<0.001). There were 3,705 patients in each group in the matched cohort. Compared with SAVR, TAVR was associated with similar in-hospital mortality (2.3% vs. 2.7%; OR, 0.85; 95% CI, 0.63-1.13) but lower incidence of major bleeding (10.9% vs. 24.0%; OR, 0.39; 95% CI, 0.34-0.44), vascular complications (4.9% vs. 6.3%; OR, 0.75; 95% CI, 0.62-0.92), ischemic stroke (1.3% vs. 3.0%; OR, 0.45; 95% CI, 0.32-0.63), myocardial infarction (0.9% vs. 3.2%; OR, 0.29; 95% CI, 0.20-0.42), or acute kidney injury (14.4% vs. 19.3%; OR, 0.71; 95% CI, 0.62-0.80). Rates of new pacemaker implantation were higher in the TAVR group (10.4% vs. 5.4%; OR, 2.03; 95% CI, 1.70-2.43). Average length of stay (LOS) was lower in patients undergoing TAVR (6.3 vs. 9.3 days; parameter estimate, 0.69; 95% CI, 0.67-0.71).
TAVR is being increasingly used in the United States as the preferred modality for AVR in patients with prior CABG. Compared with SAVR, TAVR is associated with similar in-hospital mortality, lower rates of in-hospital complications, and shorter average LOS in this important subset of patients.
STRUCTURAL: Valvular Disease: Aortic