How pairing SAVR with additional heart surgeries affects mortality risk
Performing surgical aortic valve replacement (SAVR) with concomitant procedures on older patients raises the risk of short- and long-term mortality, according to new findings published in the Journal of the American College of Cardiology.[1]
“Risk scores for SAVR with concomitant mitral or tricuspid valve procedures are not available, and decisions about these options are generally left to the local heart team because data on intermediate- and long-term outcomes are limited,” wrote first author Harun Kundi, MD, associate scientific director of the Cardiovascular Research Foundation, and colleagues. “To better understand the outcomes of patients undergoing concomitant procedures with SAVR as well as the potential role of transcatheter therapies in patients with multivalvular disease, an inventory of outcomes associated with aortic valve replacement and concomitant procedures is needed.”
Kundi et al. tracked U.S. Centers for Medicare and Medicaid Services data from 2017 to 2022, focusing on more than 100,000 SAVR patients who had no prior history of cardiac surgery, infective endocarditis or acute coronary syndrome. Exactly one-half of the study’s patients underwent a concomitant procedure when they were treated with SAVR. While 32.6% of patients underwent SAVR and coronary artery bypass graft (CABG) surgery, 8.3% underwent SAVR and a replacement of the thoracic aorta, 5.1% underwent SAVR and a mitral or tricuspid valve intervention, 2.3% underwent SAVR and CABG and a replacement of the thoracic aorta and 1.6% underwent SAVR and CABG and an additional valve intervention.
Mean ages ranged from 72 to 75 years old, and 19.4% of patients were considered frail at the time of treatment. The median follow-up period was 3.1 years.
Overall, 30-day mortality rates were 2.3% for isolated SAVR, 3.2% for SAVR and a tricuspid intervention, 7.5% for SAVR and a mitral intervention, 3.6% for SAVR and CABG, 7.6% for SAVR, CABG and a thoracic aorta replacement, and 11.7% for SAVR, CABG and a mitral valve intervention.
A similar trend was seen with long-term mortality as well. While the one- and five-year mortality rates for isolated SAVR were 5.6% and 19.1%, respectively, those rates increased considerably for almost every group that included concomitant procedures. For example, SAVR, CABG and a mitral valve intervention were associated with a one-year mortality rate of 24.7% and five-year mortality rate of 49.1%. The one exception was the combination of SAVR and a tricuspid valve intervention, which was associated with a five-year mortality rate of 18.1%; this was notably lower than the five-year mortality rate for isolated SAVR (19.1%).
“Our findings differ from recent data from the PARTNER 3 trial, which found no significant differences in mortality between isolated SAVR and SAVR plus concomitant procedures,” the authors wrote. “However, that study focused exclusively on low-risk patients with severe aortic stenosis, whereas our cohort included all Medicare fee-for-service beneficiaries aged 65 and older regardless of predicted surgical mortality and included patients undergoing planned multivalve interventions (who were excluded from PARTNER 3). Our study thus provides complementary insights into the outcomes of SAVR plus concomitant procedures in an older, higher-risk population and may help inform future evaluations of transcatheter approaches for multivalve disease.”
The group did note that their work had certain limitations. For example, clinical data such as medical imaging results and symptom burden were not part of this analysis, potentially robbing the study of important context. Also, there is always a risk that the billing codes used to organize these patient groups were misclassified by health systems. Even with those limitations in mind, however, the group emphasized that their findings have “several important implications for both clinical care and future research.”
“With the increasing use of TAVR to treat lower-risk and younger patients with aortic stenosis, patients requiring concomitant CABG or additional valve intervention represent an increasingly large proportion of elderly patients undergoing SAVR in current practice,” the author wrote. “By providing contemporary data on both short- and mid-term outcomes for these patients, our study helps to fill a critical knowledge gap that may inform both patients and their physicians considering these procedures. Given the relatively high mortality rates for these combined procedures, these data should motivate and inform future research on novel surgical and transcatheter approaches for these challenging patient subgroups. At a minimum, we believe that these findings provide a strong rationale for registries to assess outcomes for patients with aortic valve disease and concomitant coronary artery disease and/or multivalve disease, ultimately leading to focused randomized trials to inform clinical practice.”
Many of this study’s co-authors have received financial support in the past from Medtronic, Edwards Lifesciences and other companies in the medical device space.
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Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.