title: Transcatheter aortic valve replacement has improved short-term but similar midterm outcomes in isolated aortic valve replacement after prior coronary artery bypass grafting.
abstract: BACKGROUND
  An increasing number of patients with prior coronary artery bypass grafting (CABG) now present with severe aortic stenosis. The proposed benefit of surgical (SAVR) vs transcatheter aortic valve replacement (TAVR) is unknown. The objective of this study was to compare short-term and midterm outcomes of patients undergoing isolated SAVR vs TAVR in those with prior CABG.
  
  
  METHODS
  A retrospective analysis was performed of 255 patients who underwent isolated SAVR after prior CABG from January 2002 to February 2013 at Emory University. Outcomes of 148 patients undergoing SAVR (2002 to 2013) and 107 undergoing TAVR (2007 to 2013) were compared using multivariable logistic regression and analysis of variance techniques, adjusting for The Society of Thoracic Surgeons (STS) risk score. Kaplan-Meier plots were used to determine survival rates, and midterm survival between groups was compared using the Cox proportional hazards model.
  
  
  RESULTS
  TAVR patients were older (79.8 ± 7.9 years vs 72.5 ± 8.8 years, p < 0.001) but were gender equivalent (female: 24% vs 22%, p = 0.61). The preoperative ejection fraction was similar between groups (TAVR: 0.433 ± 0.131 vs SAVR: 0.469 ± 0.148%, p = 0.60). The TAVR group had a significantly higher the STS risk scores (11.8% vs 7.1%, p < 0.001). All-cause 30-day mortality was 1.9% for TAVR and 4.1% for SAVR (p = 0.32), a result that marginally favors TAVR after risk adjustment (adjusted odds ratio, 0.19; p = 0.07). Postoperative morbidity and resource utilization was significantly higher in the SAVR patients. Midterm survival was similar between the two groups after adjustment (adjusted hazard ratio, 0.78, p = 0.46).
  
  
  CONCLUSIONS
  Excellent outcomes can be achieved in SAVR or TAVR after prior CABG. Although TAVR improves short-term outcomes and resource utilization compared with SAVR, midterm mortality outcomes are similar.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Texas.
authors.forename: Tom C
authors.initials: TC
authors.lastname: Nguyen
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Vasilis C
authors.initials: VC
authors.lastname: Babaliaros
authors.affiliation: Structural Heart and Valve Center, Cardiothoracic Surgery Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Seyed Amirhossein
authors.initials: SA
authors.lastname: Razavi
authors.affiliation: Division of Biostatistics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Patrick D
authors.initials: PD
authors.lastname: Kilgo
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Chandan M
authors.initials: CM
authors.lastname: Devireddy
authors.affiliation: Structural Heart and Valve Center, Cardiothoracic Surgery Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Brad G
authors.initials: BG
authors.lastname: Leshnower
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Kreton
authors.initials: K
authors.lastname: Mavromatis
authors.affiliation: Structural Heart and Valve Center, Cardiothoracic Surgery Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Guyton
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Mihir
authors.initials: M
authors.lastname: Kanitkar
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Stam
authors.initials: S
authors.lastname: Lerakis
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: John
authors.initials: J
authors.lastname: Merlino
authors.affiliation: Structural Heart and Valve Center, Cardiothoracic Surgery Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Edward P
authors.initials: EP
authors.lastname: Chen
authors.affiliation: Structural Heart and Valve Center, Cardiothoracic Surgery Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address: vthoura@emory.edu.
authors.forename: Vinod H
authors.initials: VH
authors.lastname: Thourani
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000601:surgery*; D001026:Coronary Artery Bypass; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D065467:Transcatheter Aortic Valve Replacement / Q000401:mortality*; D016896:Treatment Outcome