SAVR/CABG vs. TAVR/PCI: Key differences when heart patients present with severe AS and CAD
When heart patients present with severe aortic stenosis (AS) and coronary artery disease (CAD), should care teams consider cardiac surgery or a more interventional approach?
According to new data presented at Society of Thoracic Surgeons (STS) 2025 meeting, and simultaneously published in The Annals of Thoracic Surgery, treatment with surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) is associated with much better long-term outcomes than transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI).
However, procedural mortality was considerably lower for TAVR/PCI, highlighting one clear benefit to avoiding surgery altogether.
“Since the approval of TAVR for the treatment of severe (AS) in patients of lower surgical risk, utilization has accelerated to include populations not studied in low-risk trials,” wrote co-first authors Vikrant Jagadeesan, MD, and J. Hunter Mehaffey, MD, MSc, two assistant professors with West Virginia University, and colleagues. “Among them, are patients with AS and concomitant CAD. Despite the prevalence of significant concomitant CAD being upwards of 25%, multidisciplinary heart teams are now re-evaluating the significance, timing, and/or even the need for concomitant revascularization in the management of AS. Evidence for PCI in conjunction with TAVR is lacking, leading to variation in practice and the selective interpretation of recommendations.”
Using years of Medicare data to compare treatment strategies
To learn more about this topic, the group explored U.S. Centers for Medicare and Medicaid Services data from nearly 38,000 patients who presented with combined AS and CAD who underwent treatment from 2018 to 2022. All patients were 65 years old or older.
While 54% of patients underwent SAVR and CABG, the other 46% underwent TAVR and PCI. The mean ages were 72.7 years old for SAVR/CABG patients and 77.1 years old for TAVR/PCI.
Among TAVR patients, 83.3% underwent elective PCI approximately three months before elective TAVR, 13.4% underwent non-emergent PCI at the same time as TAVR and the remaining 3.3% underwent PCI within three months after TAVR.
In addition, researchers noted, 53.8% of SAVR/CABG patients and 90.4% of TAVR/PCI patients underwent single vessel revascularization as opposed to multivessel revascularization.
Overall, the study’s primary endpoint—a composite of stroke, myocardial infarction, valve reintervention and death after five years—was seen in 20.4% of SAVR/CABG patients and 14.2% of TAVR/PCI patients. In fact, the rates of all-cause death, hospital readmission due to stroke and hospital readmission due to myocardial intervention and hospital readmission due to heart failure were all significantly higher after five years for patients treated with TAVR/PCI. Treatment with TAVR and PCI was also independently associated with a risk of vascular complications or the implantation of a new permanent pacemaker.
The group also evaluated in-hospital outcomes, noting that the mortality rate was much higher for SAVR/CABG (3.3%) than TAVR/PCI (1.1%). TAVR/PCI was also linked to lower rates of acute kidney injury and bleeding events, but higher rates vascular complications and permanent pacemaker implantation.
Finally, a subanalysis focused exclusively on single-vessel revascularization found that the primary endpoint was still seen less often in patients treated with SAVR/CABG than those treated with TAVR/PCI. The rates of all-cause readmission and stroke were similar for the two treatment options.
“Our analysis reiterates the trend of index procedural outcomes initially favoring PCI+TAVR, but clarifies the longitudinal benefit of stroke, MI, and death strongly in favor of CABG+SAVR,” the authors wrote.
The group also emphasized that each patient’s case must be considered separately when making these decisions. There is no one-strategy-fits-all when discussing the treatment of combined severe AS and CAD.
“Ultimately a comprehensive patient-centered heart team discussion is vital to selecting the appropriate treatment strategy in patients with severe aortic stenosis and clinically significant CAD,” they concluded.
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Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.