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

Background: As percutaneous therapeutic options expand, the optimal management of severe aortic stenosis (AS) and concomitant coronary artery disease (CAD) is being questioned between coronary artery bypass grafting and surgical aortic valve replacement (CABG+SAVR) versus percutaneous coronary intervention and transcatheter aortic valve replacement (PCI+TAVR). We sought to compare perioperative and longitudinal risk-adjusted outcomes between patients undergoing CABG+SAVR versus PCI+TAVR.

Methods: Using the United States Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all patient age 65 and older with AS and CAD undergoing CABG+SAVR or PCI+TAVR (2018-2022). Comorbidities and frailty were accounted for using validated metrics with doubly robust risk-adjustment using inverse probability weighting, multilevel regression, and competing-risk time to event analyses. The primary endpoint was 5-year composite of stroke, myocardial infarction (MI), valve reintervention and/or death.

Results: A total of 37,822 patients formed the study cohort (PCI+TAVR, n=17,413; CABG+AVR, n=20,409). Accounting for age, comorbidities, frailty, and number of vessels revascularized, PCI+TAVR was associated with lower procedural mortality (1.1% vs 3.6%, OR 0.29, p < 0.001), but higher vascular complications (OR 6.02, p < 0.001) and new permanent pacemaker (OR 1.92, p < 0.001). However, the longitudinal 5-year primary endpoint favored CABG+SAVR (20.4% vs 14.2%, OR 1.44, p < 0.001). Subgroup analyses demonstrated a benefit in the use of arterial conduit in CABG+SAVR in patients with single vessel CAD.

Conclusions: Among Medicare beneficiaries with severe AS and CAD, CABG+SAVR was associated with higher procedural mortality than PCI+TAVR but lower 5-year risk-adjusted stroke, MI, valve reintervention, and death.