Transcatheter vs. Surgical Aortic Valve Replacement in Medicare Beneficiaries with Aortic Stenosis and Significant Coronary Disease

V. Jagadeesan¹, J. Mehaffey¹, M. Kawsara², D. Chauhan³, A. Hayanga¹, C. Mascio³, J. Rankin², R. Daggubati², V. Badhwar^1
1West Virginia University, Morgantown, West Virginia ²WVU, Morgantown, West Virginia ³WVU Medicine Children's Hospital, Morgantown, West Virginia

Purpose: Significant coronary disease is common in patients requiring aortic valve replacement. The results of planned percutaneous revascularization and transcatheter aortic valve replacement (PCI/TAVR) vs surgical revascularization during valve replacement (CABG/AVR) remain poorly described. We evaluated real-world outcomes of patients undergoing TAVR vs SAVR with planned coronary revascularization.

Methods: Using the United States Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all beneficiaries aged 65 and older with a diagnosis of coronary artery disease present on admission undergoing CABG/AVR (tissue valve only) vs TAVR with elective PCI within 3 months before or after index admission between January 2018 and December 2022. Prior cardiac surgery or TAVR, coronary revascularization for STEMI, emergent admission, pure aortic insufficiency and endocarditis were excluded. Procedures were identified through diagnosis-related group and International Classification of Diseases 10th revision codes. The primary outcome was composite stroke, myocardial infarction, valve reintervention or death. Doubly robust risk-adjustment inclusive of a validated frailty metric was performed using inverse probability weighting (IPW) propensity scores as well as multilevel regression and Cox Proportional Hazards time to event analysis with competing risk. Subgroup analysis further evaluated patients requiring single vessel revascularization vs multi-vessel revascularization.

Results: A total of 37,822 beneficiaries were identified undergoing PCI/TAVR (n=17,413) or CABG/AVR (n=20,409). The PCI/TAVR cohort consisted of 14,500 (83.3%) patients receiving elective PCI 3 months before elective TAVR and 2,337 (13.4%) patients receiving non-emergent PCI during index TAVR admission with only 576 (3.3%) patients requiring PCI within 3 months after TAVR. Patients were stratified as requiring single vessel revascularization (53.8% CABG/AVR vs 90.4% PCI/TAVR) vs multivessel revascularization (46.2% CABG/AVR vs 9.6% PCI/TAVR). After risk-adjustment with IPW propensity scores, all baseline characteristics and comorbidities including frailty, were well balanced (Standard Mean Difference < 0.10). In these well-balanced groups, the index admission PCI/TAVR was associated with lower rates of major bleeding (OR 0.72, p< 0.0001), acute kidney injury (OR 0.25, p< 0.0001) and hospital mortality (OR 0.43, p< 0.0001) with no difference in stroke (OR 1.00, p=0.975) but higher new pacemaker (OR 1.59, p< 0.0001) and surgical repair of the femoral artery (OR 7.1, p< 0.0001) compared to CABG/AVR. Risk-adjusted longitudinal analysis demonstrated PCI/TAVR treatment was associated with significantly higher readmission for stroke (HR 1.10, p=0.024), myocardial infarction (HR 1.68, p< 0.0001), all-cause mortality (HR 1.09, p< 0.0001) and the composite outcomes of stroke, myocardial infarction, valve reintervention or death (HR 1.26, p< 0.0001, Figure).

Conclusion: In Medicare beneficiaries with significant coronary disease requiring aortic valve replacement and coronary revascularization, CABG/AVR was associated with improved survival and freedom from stroke or myocardial infarction compared to PCI/TAVR. These contemporary real-world data may further inform heart team decision making for patients with coronary and aortic valve disease.

Identify the source of the funding for this research project: NIH NHLBI # 2UM1 HL088925 12