Aortic valve replacement after bypass surgery: surgical (SAVR) or transcatheter (TAVR)
The situation where a patient who has undergone bypass surgery then develops significant aortic valve disease sometime during their subsequent lifetime is common. Previously the treatment choices were medical management or surgical reoperation for aortic valve replacement (SAVR). Medical treatment has been shown to have severe limitations for patients with aortic stenosis with a clinical picture of increasing disability and a projected life expectancy of roughly a 50% 2–3 years survival for symptomatic patients. On the other hand, reoperation has had its own risks, particularly for an aging group of patients. Within the last decade, catheter-borne aortic valve replacement (TAVR) has provided another option for such patients. Randomized trials of TAVR vs SAVR in high and medium risk patients have included substantial numbers of patients having had previous coronary artery bypass graft surgery (CABG). The trial with the longest follow-up, Partner-1, has shown little difference at 1-and 5-year follow-up intervals for the entire patient group, although for the patient sub-group with previous CABG or PCI there was a trend toward improved survival in the SAVR arm (P=0.10) at 5 years after randomization (1,2). Despite these data, the less-invasive nature of TAVR has led to the suggestion that it is the treatment of choice for patients with previous bypass surgery because of the advanced age of many patients with previous CABG and the desire to avoid the technical challenges associated with reoperation in the face of patent bypass grafts.