Abstract 4373444: Transcatheter Versus Surgical Revascularization in Patients with Coronary Artery Disease and Aortic Stenosis: A Systematic Review and Meta-Analysis with Reconstructed Time to Event Data

Abstract

Background: In patients with coexisting coronary artery disease (CAD) and aortic stenosis (AS), the comparative time-dependent event rates for percutaneous coronary intervention (PCI) with transcatheter aortic valve replacement (TAVR) versus coronary arteries bypass grafting (CABG) with surgical aortic valve replacement (SAVR) remain poorly characterized. Research Question: What is the comparative efficacy and safety of PCI + TAVR versus CABG + SAVR in patients with CAD and AS, considering both short- and long-term clinical outcomes? Methods: We searched electronic databases to identify studies comparing PCI + TAVR with CABG + SAVR that reported relevant clinical outcomes. Pairwise meta-analysis was conducted using a random-effects model, and reconstructed time-to-event analysis were performed using R version 4.2.2. Results: We included 14 studies comprising a total of 162,225 patients. Compared to CABG + SAVR, the PCI + TAVR group demonstrated significantly lower rates of early mortality (OR 0.52; 95% CI 0.35–0.78), re-thoracotomy (OR 0.19; 95% CI 0.05--0.76), atrial fibrillation (OR 0.16; 95% CI 0.09–0.28), acute kidney injury (OR 0.29; 95% CI 0.18–0.47), major bleeding (OR 0.51; 95% CI 0.28–0.94), and cardiac tamponade (OR 0.14; 95% CI 0.03–0.77). However, PCI + TAVR was associated with higher rates of pacemaker implantation (OR 2.15; 95% CI 1.46–3.17) and vascular complications (OR 5.94; 95% CI 3.99–8.85). There were no significant differences between the two strategies in the rates of stroke (OR 0.71; 95% CI 0.46–1.10), MI (OR 0.53; 95% CI 0.22–1.27), or valvular reintervention (OR 0.85; 95% CI 0.56–1.31). Reconstructed time-to-event analysis revealed that PCI + TAVR significantly reduced all-cause mortality at 1 year (p < 0.001), but was associated with increased mortality beyond 1 year (p < 0.001). MI (p = 0.01) and repeat revascularization (p = 0.007) were significantly higher in the percutaneous arm, although, percutaneous group had a longer stroke-free survival time (p = 0.015). Conclusions: Our meta-analysis suggests that the percutaneous approach offers better short-term outcomes, whereas the surgical approach provides superior long-term benefits.