Early and mid-term outcomes in patients undergoing transcatheter aortic valve implantation after previous coronary artery bypass grafting

ORIGINAL ARTICLE European Journal of Cardio-Thoracic Surgery 41 (2012) 499–504 doi:10.1093/ejcts/ezr041 Advance Access publication 11 November 2011 Gregory Ducrocqa,*, Nawwar Al-Attarb, Dominique Himberta, David Messika-Zeitouna, Bernard Iunga, Fleur Descouturesa, Patrick Natafb and Alec Vahaniana a b Department of Cardiology, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Bichat-Claude Bernard, Paris, France Department of Cardiovascular Surgery, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Bichat-Claude Bernard, Paris, France Received 7 April 2011; received in revised form 20 July 2011; accepted 26 July 2011 Abstract OBJECTIVES: Surgical aortic valve replacement in patients with previous coronary artery bypass grafting (CABG) carries a high mortality. Transcatheter aortic valve implantation (TAVI) has been shown to be successful in high risk subgroups of patients. Our goal is therefore to evaluate the impact of a history of CABG on the outcome of patients who undergo TAVI. METHODS: From October 2006 to June 2010, among the 201 patients selected to undergo TAVI, 54 (27%) had a history of CABG. Outcomes were prospectively collected. RESULTS: The 30-day outcome was not different between patients with previous CABG vs. those without, in particular as regards mortality (respectively, 5.6% vs. 10.9%; P = 0.25). Mid-term survival (mean FU: 7 ± 9 months) was not different at 2 years between patients with previous CABG vs. patients without (65.7 ± 6.2% vs. 80.0 ± 7.7% respectively; P = 0.12). In multivariate analysis, CABG was not associated with an excess mid-term mortality after TAVI. CONCLUSIONS: Previous CABG does not adversely affect outcome in patients undergoing TAVI. If confirmed by larger prospective series and ideally by a randomized trial comparing CABG vs. redo surgery, this observation might lead the heart team to consider TAVI as an attractive option in the population of high risk patients with aortic stenosis and previous CABG. Keywords: Transcatheter aortic valve implantation • Coronary artery bypass grafting INTRODUCTION Severe aortic stenosis (AS) in patients with previous coronary artery bypass grafting (CABG) is a common clinical problem. In this case, redo aortic valve replacement (AVR) is indicated but carries a high risk [1–4]. Transcatheter aortic valve implantation (TAVI) has therefore been suggested as an alternative to surgery in this high-risk group of patients [5]. However, to the best of our knowledge, no study has specifically evaluated patients with previous CABG undergoing TAVI. Our goal was therefore to evaluate the impact of a history of CABG on the outcome of patients who undergo TAVI. MATERIALS AND METHODS algorithm for management of those patients has been previously described [6]. Briefly, the decision to perform TAVI was taken in patients with contraindications to, or at high risk for AVR [7, 8], and with anatomy suitable for TAVI [5]. Patients with a history of previous CABG were considered at high risk for surgery and this gave a further incentive for TAVI. Comorbidities were evaluated using the Charlson comorbidity index [9]. Coronary angiography was systematically performed as a screening test. Significant coronary stenosis was defined as ≥70% luminal diameter narrowing of an epicardial artery measured in the ‘worst view’ angiographic projection (≥50% for left main stem). Baseline characteristics were prospectively collected. In addition, for the patients with previous CABG we specifically recorded date, number and type of grafts (mammary vs. saphenous vein graft); as well as number and type of patent grafts at the time of TAVI. Patients TAVI procedure From October 2006 to June 2010, all high-risk patients with severe symptomatic AS evaluated for TAVI in our institution underwent multidisciplinary evaluation by a heart team. The The technical aspects of the procedure have been described elsewhere [6]. The transfemoral approach was considered as the © The Author 2011. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. * Corresponding author. Département de Cardiologie, Hôpital Bichat-Claude Bernard, 46 rue Henri, Huchard 75018, Paris. Tel: +331-40-258661; fax: +331-40258865; e-mail: (G. Ducrocq). ADULT CARDIAC Early and mid-term outcomes in patients undergoing transcatheter aortic valve implantation after previous coronary artery bypass grafting 500 G. Ducrocq et al. / European Journal of Cardio-Thoracic Surgery first option, and transapical, subclavian or transiliac alternatives were used in patients with contraindications to the transfemoral approach. From October 2006 to May 2008, the Edwards Sapien was the only prosthesis used. From May 2008, the Medtronic Corevalve® System was also used according to the anatomical characteristics of patients [6]. Follow-up All clinical events were prospectively recorded during the hospital stay and follow-up. Clinical and transthoracic echocardiography follow-up were obtained in all survivors at 1 month, 6 months, 1 year, and then annually. Implantation success was defined as valve implantation in the correct position. All cause mortality was considered when reporting 30-day and mid-term mortality. Troponin I was measured within the first 24 hr after TAVI. All electrocardiograms were recorded before and after the procedure. Periprocedural myocardial infarction (MI) was defined as an increase in troponin of more than five times the 99th percentile upper range limit (URL) associated with new ischaemic signs (e.g. chest pain or shortness of breath, ventricular arrhythmias, new or worsening heart failure, new ST-segment changes, haemodynamic instability, or imaging evidence of new loss of viable myocardium or new wall motion abnormality). Stroke was defined as a rapid onset of a focal or global neurological deficit confirmed by a magnetic resonance imaging or a computed tomography scan. Severe bleeding was defined as bleeding in a critical organ area or causing death or any overt bleeding requiring packed red blood cell transfusion. Major vascular complications were defined as any aortic dissection or access-related vascular injury leading to either death, need for significant blood transfusion (≥4 units), unplanned intervention or irreversible end organ damage. Statistical analysis Quantitative variables were expressed as mean ± standard deviation or median and interquartile ranges [25–75th percentiles]. Inter-group comparisons were performed using the unpaired Student t-test, the Mann–Whitney U test, or the χ 2 test as appropriate. Cumulative survival curves were determined according to the Kaplan–Meier method. Univariate analysis of the predictive factors of in-hospital mortality used the unpaired Student t-test or the χ 2 test, where appropriate. Univariate analysis of the predictive factors of late mortality was performed using a Cox univariate model. To evaluate the effect of experience on mid-term (...truncated)