12 Transcatheter versus surgical approach for severe aortic stenosis with concomitant coronary artery disease: a systematic review and meta-analysis of early and mid-term outcomes
Bibliographic record
Abstract
Introduction Coronary artery disease (CAD) is frequently encountered in patients undergoing transcatheter aortic valve replacement (TAVR). Contemporary recommendations advocate revascularisation of patients with severe aortic stenosis (AS) and concomitant significant coronary artery disease (CAD) by either a surgical or percutaneous approach. We undertook a systematic review and meta-analysis to evaluate the early and mid-term outcomes of patients who underwent surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) against patients who had TAVR and percutaneous coronary intervention (PCI). Methods A search of Medline and Embase was performed to identify studies comparing transcatheter and surgical approaches. Our search was independently screened by two investigators. Random effects meta-analyses with the Mantel-Haenzsel method were performed to estimate the odds of adverse outcomes. Analyses were performed with RevMan (Review Manager version 5.3.5, Nordic Cochrane Centre, Denmark). Results 1770 participants from six studies (5 observational, 1 randomised) were included in the meta-analysis (631 TAVR and PCI, 1139 SAVR and CABG). The mean age of participants was 79.2 years and 58.9% were male. TAVR was performed via both transapical/transaortic and transfemoral routes, using both self-expandable and balloon expandable valve systems. PCI was conducted either concomitant to TAVR or up to a year before. Risk of bias assessed using the ROBINS-I tool, identified 1 study at low risk and 4 studies at high risk of bias, predominately due to selection bias. There were no significant differences in effect estimates for early and mid-term mortality (OR: 0.78; 95% CI, 0.50-1.20 and OR: 1.09; 95% CI, 0.80-1.49) or myocardial infarction (OR: 0.52 95% CI, 0.20-1.33 and OR: 1.34; 95% CI, 0.67-2.65) No significant difference was noted in early cerebrovascular accidents (OR: 0.80; 95% CI, 0.35-1.87). A transcatheter approach was associated with a higher rate of new permanent pacemaker insertion (OR: 3.47; 95% CI, 1.98-6.06) and major vascular complications (OR: 14.44; 95% CI, 4.42-47.16), but a lower rate of acute kidney injury (OR: 0.41; 95% CI, 0.19-0.91). Conclusion These data suggest that in patients with severe AS and CAD a transcatheter approach has comparable outcomes to a surgical approach. Pending high level evidence, surgical risk assessment should form the cornerstone of individualised decision making. Conflict of Interest None
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.012 | 0.023 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.017 | 0.041 |
| Bibliometrics | 0.006 | 0.006 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.003 | 0.001 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.002 | 0.002 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".