Coronary artery disease (CAD) and aortic stenosis (AS) are both diseases of aging and have even been postulated to share common risk factors. Approximately 60% of patients with critical AS have CAD. Multiple studies on patients without valvular heart disease shows that CABG provides a mortality advantage over PCI in patients with severe CAD and that the advantage increases with the extent of the CAD. However, we do not know whether the presence of critical AS alters this relationship by increasing the complexity of surgery or by decreasing the expected survival even after a successful operation.
Alperi et al report a comparison of outcomes between patients with moderate to severe CAD who underwent PCI and TAVR and those who underwent CABG and SAVR. Predicted Risk of Mortality was 5.8%, and the mean SYNTAX score was 27. Roughly one third of patients had SYNTAX scores >33. PCI, TAVR, CABG, and SAVR were performed according to contemporary standards; complete revascularization was reported in 70% of the percutaneously treated patients and 98% of those undergoing surgery. Median follow-up was 3 years.
The primary composite outcome of all-cause mortality, nonprocedural myocardial infarction, new coronary revascularization, or stroke occurred with greater frequency among patients undergoing PCI and TAVR: 15.7/100 patient-years compared with 10.3/100 patient-years for CABG and SAVR. All-cause mortality at 5 years was 38.1% among TAVR/PCI patients and 32.2% among SAVR/CABG patients, with rates of 11.6/100 patient-years and 8.4/100 patient years, respectively.
The greatest difference was seen in the frequency of revascularization: 24.4% in the TAVR/PCI group versus 4.1% for CABG and SAVR. The incidence rates themselves are not: 3.3/100 patient-years versus 0.7/100 patient-years, respectively. In parallel, the rates of myocardial infarction were also low: 1.9/100 patient-years and 1.5/100 patient-years.