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

Summary

In a 37,822-patient Medicare cohort with AS and CAD, PCI+TAVR had lower procedural mortality but higher vascular complications and pacemaker use. After risk adjustment, CABG+SAVR yielded superior 5-year composite outcomes (stroke/MI/reintervention/death) than PCI+TAVR, with additional benefit of arterial conduits in single-vessel CAD.

Key Findings

• PCI+TAVR had lower procedural mortality than CABG+SAVR (1.1% vs 3.6%; OR 0.29; P<.001).
• PCI+TAVR had higher vascular complications (OR 6.02; P<.001) and new permanent pacemaker implantation (OR 1.92; P<.001).
• The 5-year composite outcome (stroke, MI, valve reintervention, or death) favored CABG+SAVR (20.4% vs 14.2%; OR 1.44; P<.001).
• Use of arterial conduits in CABG+SAVR was beneficial in single-vessel CAD.

Clinical Implications

For AS with significant CAD, heart teams should weigh lower procedural risk of PCI+TAVR against superior 5-year outcomes with CABG+SAVR; surgical strategies using arterial conduits may further enhance benefit in single-vessel CAD. Shared decision-making should incorporate long-term prognosis, revascularization completeness, and pacemaker risk.

Limitations

• Observational design with potential residual confounding and selection bias
• Claims-based data limit anatomical and procedural granularity (lesion complexity, completeness of revascularization)

Future Directions

Prospective comparative trials or pragmatic registries integrating anatomical complexity, physiologic assessments, and patient-centered outcomes could refine selection algorithms; cost-effectiveness analyses across risk strata are warranted.