Transcatheter Aortic Valve Implantation or Surgical Aortic Valve Replacement as Redo Procedure After Prior Coronary Artery Bypass Grafting

doi:10.1016/j.athoracsur.2011.05.106

The Annals of Thoracic Surgery

Volume 92, Issue 4, October 2011, Pages 1324-1331

Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.

https://doi.org/10.1016/j.athoracsur.2011.05.106 Get rights and content

Background

The perioperative risk for redo surgical aortic valve replacement (S-AVR) in patients with severe aortic stenosis and prior coronary artery bypass grafting (CABG) is increased. Transcatheter aortic valve implantation (TAVI) represents an alternative. We assessed the perioperative and mid-term clinical outcome of patients undergoing S-AVR or TAVI.

Methods

In a retrospective observational, comparative study, 40 consecutive patients underwent redo operation with S-AVR or TAVI between April 2005 and April 2010. Median sternotomy and extracorporeal circulation were used for S-AVR; TAVI access was transfemoral (n = 27; 67.5%), transapical (n = 11; 27.5%), or transsubclavian (n = 2; 5.0%). Clinical and echocardiographic follow-up was at 30 days and 6 months.

Results

TAVI patients were older (78.5 ± 6 vs 70.6 ± 8 years, p < 0.001) and presented higher logistic (33.5 ± 17 vs 20.2 ± 14, p < 0.001) European System for Cardiac Operative Risk Evaluation scores. All-cause mortality was 2.5% in both groups and major adverse cardiac and cerebrovascular event rates were comparable (7.5% TAVI vs 17.5% S-AVR, p = 0.311) after 30 days. TAVI was associated with a higher rate of permanent pacemaker implantation (30% vs 0%, p < 0.001) and grade II residual aortic regurgitation in 14%. Incidence of cerebrovascular events was 7.5% in S-AVR vs 2.5% in TAVI (p = 0.61).

Conclusions

In elderly, high-risk patients after prior CABG, conventional aortic valve replacement and TAVI are comparable treatment options with favorable clinical outcome. A redo operation itself does not sufficiently justify a TAVI approach.

Section snippets

Patients and Methods

The Institutional Review Board approved the study and individual patient consent was waived.

Results

Between April 2005 and April 2010, 40 patients received S-AVR as a redo procedure after previous CABG. Thirty-five patients (87.5%) were treated with biologic, 2 patients (5%) with mechanical valve prostheses, and 3 patients (7.5%) received an apical-descendens conduit.

Baseline patient characteristics are reported in Table 1. Sex distribution and comorbidities were similar in both groups, except that the TAVI patients were significantly older and presented more frequently with peripheral

Comment

The present study shows that aortic valve replacement in patients with previous CABG can be performed with favorable and similar medium-term clinical results and low mortality by S-AVR as well as by TAVI.

Patients with previous cardiac interventions—most frequently CABG—are considered to be at increased perioperative risk when undergoing redo cardiac operations and constitute 5% to 16% of all patients undergoing S-AVR [12, 13, 14]. With this study we assessed the outcome of TAVI and compared

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Cited by (43)

Comparison of Outcomes and Discharge Location After Transcatheter vs. Surgical Aortic Valve Replacement With Prior Coronary Artery Bypass Grafting
2023, Structural Heart
Citation Excerpt :
This study shows that in propensity-matched patients with prior CABG who undergo TF-TAVR vs. reoperative SAVR for severe aortic stenosis, TF-TAVR results in less in-hospital morbidity, shorter postprocedural ICU and hospital stays, and higher likelihood of home discharge. Previous studies have shown no difference in mortality between TAVR and SAVR after CABG.5,8–12,27,28 As a result, postprocedural morbidity, length of hospital stay, and discharge location are important factors in determining the ideal procedure for a particular patient.
Published trials have shown that transcatheter aortic valve replacement (TAVR) is a safe alternative to surgical aortic valve replacement (SAVR) after prior coronary artery bypass grafting (CABG). However, differences in morbidity and discharge location between the 2 procedures are less thoroughly characterized.
From January 1, 2006 to January 7, 2020, 1059 patients with severe aortic stenosis after CABG underwent either SAVR (n = 315/30%), transfemoral TAVR (TF-TAVR) (n = 575/54%), or alternative access TAVR (n = 169/16%) at a single, tertiary care, academic institution. Propensity-weighted matching was used to compare morbidity, mortality, length of postprocedure stay, and nonhome discharge between TF-TAVR (effective n = 163) and SAVR (effective n = 163) groups.
Among propensity-weighted groups, the TF-TAVR group experienced fewer transfusions than the SAVR group (effective n = 16 [9.5%] vs. 132 [81%]; p < 0 .0001), less new-onset atrial fibrillation (effective n = 5.1 [3.1%] vs. 43 [27%]; p = 0.009), and less prolonged mechanical ventilation >24 hours (effective n = 0.41 [0.25%] vs. 30 [18%]; p <0.0001). Permanent pacemaker implant was 9.3% (effective n = 13) after TF-TAVR vs. 5.5% (effective n = 7.9; p = 0.2) after SAVR, stroke 0.41% (effective n = 0.67) vs. 2.1% (effective n = 3.5; p = 0.2), and operative mortality 0.5% (effective n = 0.8) vs. 1.7% (effective n = 2.8; p = 0.8). The TF-TAVR group had shorter postprocedure lengths of stay (2.0 vs. 7.6 days; p < 0.0001). Discharge home was more common after TF-TAVR than SAVR (effective n = 156 [95%] vs. 118 [73%]; p = 0.01).
For patients developing severe aortic stenosis after CABG, TF-TAVR rather than SAVR should be strongly considered because of lower morbidity, shorter length of stay, and greater likelihood of home discharge.
Outcomes After Acute Type A Aortic Dissection in Patients With Prior Cardiac Surgery
2019, Annals of Thoracic Surgery
Limited prior studies suggest patients with acute type A aortic dissection (ATAAD) and prior cardiac surgery are at increased risk for major complications compared with those without a prior sternotomy. We sought to investigate the impact of prior cardiac surgery on ATAAD outcomes across a multicenter regional consortium.
Patients undergoing surgical intervention for ATAAD in a regional Society of Thoracic Surgeons database between 2002 and 2017 were stratified by prior cardiac surgery (reoperative) status. Demographics, operative characteristics, outcomes and cost data were compared by univariate analysis. Multivariable regression models assessed risk-adjusted impact of reoperative status on outcomes.
A total of 1,332 patients underwent surgery for ATAAD, of whom 138 (10.4%) were reoperations. Reoperative patients were older (63 vs. 58 years, p < 0.01) with more comorbidities. These patients had longer median cardiopulmonary bypass times (218 vs 177 minutes, p < 0.01) and increased blood product utilization; however rates of aortic arch, root, and valve procedures were similar. On unadjusted analysis operative mortality was higher in reoperative patients (28% vs 15%, p < 0.01) with a longer total length of stay (13 vs 10 days, p = 0.02). Reoperative patients exhibited a trend toward decreased mortality at high-volume centers (25.7% vs 37.9%, p = 0.19). After risk adjustment reoperative status remained associated with mortality (odds ratio, 2.1; p < 0.01) as well as composite morbidity–mortality (odds ratio, 2.2; p < 0.01).
In this multicenter cohort undergoing repair of ATAAD prior cardiac surgery was associated with an increased morbidity and mortality. Centralization to high-volume centers and emerging technologies may improve outcomes in this high-risk population.
Transcatheter Aortic Valve Replacement Versus Surgical Aortic Valve Replacement: A Prior Sternotomy Is Not the Problem<sup>∗</sup>
2018, JACC: Cardiovascular Interventions
Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Prior Cardiac Surgery in the Randomized PARTNER 2A Trial
2018, JACC: Cardiovascular Interventions
Citation Excerpt :
Finally, bleeding was significantly more common among patients with PCS who underwent SAVR than TAVR, driven by life-threatening or disabling bleeding. This finding is fairly expected, given that repeated sternotomy and lysis of adhesions are required during the SAVR procedure, and it is in line with the increase in access-related major vascular complications and with previous publications reporting higher rates of bleeding and blood transfusion among patients with PCS who underwent SAVR compared with TAVR (15,16,27). It is noteworthy that the increase in bleeding event rates had no effect on mortality or length of hospitalization in the present study.
The aim of this study was to further evaluate clinical outcomes in patients with and without PCS.
Prior cardiac surgery (PCS) is associated with increased surgical risk and post-operative complications following surgical aortic valve replacement (SAVR), but whether this risk is similar in transcatheter aortic valve replacement (TAVR) is unclear.
In the PARTNER 2A (Placement of Aortic Transcatheter Valve) trial, 2,032 patients with severe aortic stenosis at intermediate surgical risk were randomized to TAVR with the SAPIEN XT valve or SAVR. Adverse clinical outcomes at 30 days and 2 years were compared using Kaplan-Meier event rates and multivariate Cox proportional hazards regression models. The primary endpoint of the PARTNER 2 trial was all-cause death and disabling stroke.
Five hundred nine patients (25.1%) had PCS, mostly (98.2%) coronary artery bypass grafting. There were no significant differences between TAVR and SAVR in patients with or without PCS in the rates of the primary endpoint at 30 days or 2 years. Nevertheless, an interaction was observed between PCS and treatment arm; whereas no-PCS patients treated with TAVR had higher rates of 30-day major vascular complications than patients treated with SAVR (adjusted hazard ratio: 2.66; 95% confidence interval: 1.68 to 4.22), the opposite was true for patients with PCS (adjusted hazard ratio: 0.27; 95% confidence interval: 0.11 to 0.66) (p_interaction <0.0001). A similar interaction was observed for life-threatening or disabling bleeding.
In the PARTNER 2A trial of intermediate-risk patients with severe aortic stenosis undergoing SAVR versus TAVR, the relative risk for 2-year adverse clinical outcomes was similar between TAVR and SAVR in patients with or without PCS.
Transcatheter aortic valve replacement versus surgical aortic valve replacement in patients with previous coronary artery bypass surgery: A systematic review and meta-analysis
2016, International Journal of Cardiology
Patients with severe aortic stenosis (AS) and previous coronary artery bypass graft (CABG) surgery have increased risk for aortic valve replacement. Whether surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) offers better outcomes in this population is unclear. We aimed to assess outcomes of TAVR and SAVR in patients with previous CABG.
A systematic literature search of Medline, EMBASE and Cochrane library was conducted. Studies that reported clinical outcomes (perioperative or mid-term all-cause-mortality, cardiovascular mortality, pacemaker implantation, hospital duration and stroke) were included. Random-effect modeling was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs).
Five cohort studies including a total of 872 patients (423 in TAVR, 449 in SAVR) were analyzed. STS scores were comparable between the two groups. No difference in all-cause-mortality, cardiovascular mortality and stroke at 30 days, 1 year and total follow-up period was seen between the two groups. TAVR patients had higher pacemaker implantation rates (OR 3.41, 95% CI 1.66–6.38, p < 0.001, I² = 21%) and shorter hospital stay (− 2.63 days, 95% CI − 5.20 to − 0.04, p = 0.05, I² = 43%).
Patients with previous CABG who underwent TAVR had similar perioperative and long-term survival while experiencing more pacemaker implantations and shorter hospital stay compared to those who had SAVR making TAVR a safe and efficacious alternative to SAVR.
Impact of transcatheter aortic valve implantation in the treatment of aortic valve disease after previous coronary artery bypass
2016, Annales de Cardiologie et d'Angeiologie
Les patients aux antécédents de pontage aorto-coronarien et présentant une valvulopathie aortique sont un groupe à risque élevé pour la chirurgie conventionnelle redux. L’implantation de valve aortique par voie trans-cathéter (TAVI) pourrait être une alternative pour leur prise en charge. Le but de cette étude est d’évaluer l’impact des TAVI dans la prise en charge des valvulopathies aortiques après une revascularisation coronaire chirurgicale préalable.
Il s’agit d’une étude rétrospective, observationnelle monocentrique incluant 87 patients ayant bénéficié d’une chirurgie traditionnelle ou d’un TAVI dans le période allant de janvier 2007 à décembre 2013. Les abords pour le TAVI était trans-fémoral, trans-apical et par l’artère sous-clavière.
L’introduction des techniques interventionnelles a multiplié par deux le nombre de patients redux de pontage traités pour une valvulopathie aortique. Sur la deuxième période 30 % de moins de patients ont été opérés par la chirurgie conventionnelle, ce qui a permis une amélioration des résultats postopératoires. Cette étude nous a permis de remarquer une différence des populations de patients traités en termes de facteurs de risques opératoires n’autorisant dans cette série aucune comparaison sans biais entre les deux techniques. La mortalité hospitalière était de 6,4 % pour la chirurgie conventionnelle aortique et de 20 % pour les implantations aortiques trans-cathéter.
La chirurgie conventionnelle reste le traitement de référence pour la prise en charge des valvulopathies mais le TAVI devient un complément indispensable pour permettre de mieux sélectionner les patients avant la chirurgie offrant des perspectives thérapeutiques nouvelles pour les autres.
Patients with a history of coronary artery bypass and aortic valve disease constitute a high-risk group for conventional redo surgery. The transcatheter aortic valve implantation (TAVI) may be an alternative for high-risk patients. The purpose of this study is to evaluate the impact of TAVI in the treatment of aortic valve disease after previous surgical coronary artery revascularization.
This is a single-center retrospective, observational study, including 87 patients undergoing surgery for surgical heart valve replacement or TAVI from January 2007 to December 2013.
The introduction of transcatheter aortic valve implantation techniques has doubled the number of redo patients treated for aortic valve disease. From 2010 to 2013, the patients treated by conventional surgery diminished by 30%, with improved postoperative outcomes. This study allowed us to notice differences in patient's in terms of operative risk factors. For the same reasons no comparison was possible between 2 subgroup of patients. Hospital mortality was 6.4% for conventional aortic surgery and 20% for transcatheter aortic valve treatment.
Surgery remains the standard treatment for aortic valve disease even in redo patients, but TAVI becomes a very interesting tool as it may represent a tailored approach for our patients.

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^*: Drs Stortecky and Brinks contributed equally.

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Original articleAdult cardiacTranscatheter Aortic Valve Implantation or Surgical Aortic Valve Replacement as Redo Procedure After Prior Coronary Artery Bypass Grafting

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

Decision-making and outcomes in severe symptomatic aortic stenosis

J Heart Valve Dis

A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease

Eur Heart J

Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up

Circulation

Circulation

Original article
Adult cardiac
Transcatheter Aortic Valve Implantation or Surgical Aortic Valve Replacement as Redo Procedure After Prior Coronary Artery Bypass Grafting