E. Aguayo1,2, O. Kwon1,2, T. Coaston1, S. Sakowitz1, S. Mallick1, J. Hadaya1, Y. Sanaiha1, P. Benharash1 1Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department Of Surgery, Los Angeles, CA, USA 2Los Angeles County Harbor-UCLA Medical Center, Department Of Surgery, Torrance, CA, USA
Introduction:
With the aging US population and improvements in diagnostics, the volume of patients with aortic stenosis has steadily risen. A significant proportion of these patients may have received prior cardiac surgery such as coronary artery bypass grafting (CABG). Although transcatheter aortic valve replacement (TAVR) has supplanted surgery (SAVR) in many cases, its outcomes in patients with prior CABG remain generally unexplored. In the present work, we examined the acute outcomes of SAVR and TAVR in a national cohort of patients with prior CABG.
Methods:
The 2016-2021 Nationwide Readmissions Database was queried to identify all adult patients (≥18 years) with a previous history of CABG receiving TAVR or SAVR. Patients undergoing other concomitant cardiac procedures were excluded. The primary endpoint was in-hospital mortality while several postoperative complications (stroke, thromboembolic, cardiac, renal, respiratory, and infectious complications), hospitalization costs, length of stay and 30-day nonelective readmissions, were also considered. Trends in the utilization of TAVR and SAVR during the study period were assessed. Multivariable regression models were developed to examine the association of replacement modality with outcomes of interest.
Results:
Among an estimated 771,469 patients, 1.7% of SAVR and 14.6% of TAVR patients had a prior CABG. Utilization of SAVR decreased from1,619 cases in 2016 to 799 in 2021 (P<0.001). In contrast, TAVR increased in use from 8,683 cases in 2016 to 11,009 in 2021 (P<0.001). Compared to TAVR, patients undergoing SAVR were younger (68.2 vs 78.8 years, P<0.001), less likely to be male (76.5 vs 78.7%, P=0.003) and had a similar Elixhauser Comorbidity Index (5.7, 95% CI 1.6-9.7 vs 5.6, 95% CI 1.9-9.3, P=0.79). After multivariable adjustment and TAVR as reference, SAVR was independently associated with increased odds of acute mortality (AOR 5.84, 95% CI 4.48-7.61) as well as thrombotic (AOR 2.41, 95% CI 1.64-3.64), respiratory (AOR 5.39, 95% CI 4.68-6.19), and infectious complications (AOR 1.91, 95% CI 1.53-2.40) complications. SAVR was associated with increased hospitalization costs (β+ $6,799, P<0.001), length of stay (β+ 4.3 days, P<0.001). There was no difference in odds of 30-day readmissions (AOR 1.09, 95% CI 0.94-1.2). Odds of mortality increased with age while the impact of SAVR was more pronounced with advancing age (Figure).
Conclusion:
Compared to TAVR, SAVR appeared to be associated with increased risk of acute mortality and complications among patients with prior CABG. Appropriate risk stratification and anatomic factors should be considered when selecting replacement modality in such patients.