Transcatheter Versus Surgical Approach for the Treatment of Aortic Stenosis in Patients With Concomitant Coronary Artery Disease: A Systematic Review and Meta-Analysis.

Aortic stenosis (AS) with concomitant coronary artery disease (CAD) requires an approach that addresses both valvular and coronary pathology. While surgical aortic valve replacement (SAVR) with coronary artery bypass graft (CABG) has long been the standard treatment, transcatheter aortic valve replacement (TAVI) with percutaneous coronary intervention (PCI) has become a less invasive alternative. This meta-analysis compares the clinical outcomes of TAVI + PCI versus SAVR + CABG in patients with AS and concomitant CAD. A systematic review and meta-analysis were conducted according to PRISMA guidelines. Fourteen studies, including two randomized controlled trials (RCTs) and 12 observational studies, with a total of 187,189 patients (31,298 in the TAVI + PCI group and 155,891 in the SAVR + CABG group) were included. Outcomes analyzed included 30-day mortality, stroke, major adverse cardiovascular and cerebrovascular events (MACCE), coronary reintervention, atrial fibrillation, major bleeding, vascular complications, acute kidney injury (AKI), perioperative myocardial infarction MI), permanent pacemaker implantation (PPI), length of hospital stay, and long-term survival. Patients undergoing TAVI + PCI were generally older (ranging from 76.3 ± 3.7 to 83.6 ± 3.7 years) and had higher rates of chronic kidney disease (CKD) compared to the SAVR + CABG group. Other comorbidities, such as diabetes and hypertension, were comparable between groups. The EuroSCORE varied widely (3 ± 2.2 to 36.1 ± 18.1), reflecting a mix of surgical risk profiles. TAVI + PCI was associated with a lower 30-day mortality rate (OR: 0.63, 95% CI: 0.37-1.07, p = 0.09), though the result was not statistically significant. Stroke rates were comparable between the two groups (OR: 0.89, 95% CI: 0.70-1.14, p = 0.36). There was no significant difference in MACCE (OR: 0.96, 95% CI: 0.50-1.84, p = 0.91). However, coronary reintervention was significantly higher in the TAVI + PCI group (OR: 4.32, 95% CI: 2.58-7.23, p < 0.00001). TAVI + PCI was associated with an 82% lower risk of atrial fibrillation (OR: 0.18, 95% CI: 0.11-0.30, p < 0.00001) but a similar risk of major bleeding (OR: 0.71, 95% CI: 0.38-1.31, p = 0.27). Vascular complications were significantly higher in the TAVI + PCI group (OR: 3.01, 95% CI: 1.52-5.93, p = 0.002), while perioperative AKI was lower (OR: 0.46, 95% CI: 0.21-0.99, p = 0.05). There was no significant difference in perioperative MI (OR: 0.78, 95% CI: 0.34-1.78, p = 0.55). However, TAVI + PCI was associated with a higher likelihood of PPI (OR: 2.14, 95% CI: 1.88-2.43, p < 0.00001). The length of hospital stay was significantly shorter in the TAVI + PCI group (mean difference: -3.45 days, 95% CI: -5.79 to -1.12, p = 0.004). Long-term survival favored TAVI + PCI (OR: 0.63, 95% CI: 0.49-0.80, p = 0.0002). TAVI + PCI appears to be a viable alternative to SAVR + CABG, particularly in elderly or high-risk patients, with advantages such as lower long-term mortality, reduced atrial fibrillation, shorter hospital stays, and lower AKI rates. However, it carries a higher risk of coronary reintervention, vascular complications, and the need for PPI. These findings highlight the importance of individualized patient selection to balance risks and benefits.