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TAVR Provides Benefits Over SAVR in Patients with Prior CABG

Key findings

  • Patients who underwent TAVR during the 2012 to 2014 study period were more likely to be older, female and have more comorbidities
  • TAVR is associated with similar in-hospital mortality as SAVR for patients with prior CABG but fewer complications
  • TAVR continues to become increasingly favored over SAVR for patients with prior CABG

Aortic stenosis (AS) is a stiffening of the aortic valve which typically culminates in heart failure. Aortic valve replacement (AVR) is the standard treatment for AS. However, many patients with AS have undergone prior coronary artery bypass graft (CABG) surgery, which can make surgical aortic valve replacement (SAVR) technically challenging for many reasons including the risk of damaging the bypass grafts. Since SAVR puts these patients at higher risk of morbidity and mortality, management has shifted toward an alternative strategy, transcatheter aortic valve replacement (TAVR).

A multicenter team, including Massachusetts General Hospital researchers Sammy Elmariah, MD, and Ignacio Inglessis, MD, director, Adult Congenital Heart Disease Interventions, conducted a study of outcomes in Circulation: Cardiovascular Interventionsfor 15,055 first-time SAVR and TAVR patients who also had prior CABG from 2012 and 2014 in the publicly accessible National Inpatient Sample (NIS) database. Patient baseline characteristics used as variables in the analyses included demographics and additional disorders and risk factors. Specific outcomes measured in their analysis included:

  • All-cause in-hospital mortality
  • Length of stay (LOS)
  • Myocardial infarction (MI)
  • Stroke
  • Bleeding
  • Vascular complications
  • Acute kidney injury (AKI) requiring and not-requiring dialysis
  • Discharge disposition for survivors.

The team created matched cohorts (3,880 SAVR patients versus 3,880 TAVR patients matched by baseline characteristics) and unmatched cohorts (all 6,170 SAVR versus all 8,885 TAVR patients) and analyzed them using linear and logistic regression with univariate and multivariate models.

The findings indicate that over the three-year period, TAVR became the preferred method for patients with prior CABG. For those without CABG, SAVR declined in use but remained the preferred approach. Those who underwent TAVR tended to be older (mean age 80.7 years versus 73.6 years) and female (25.8% versus 18.6%), and the prevalence of comorbidities at the time of the procedure, (e.g. heart failure, hypertension, chronic renal failure, pulmonary disease, and cancer) was higher in the TAVR cohort. The statistical analyses of outcomes showed similar in-hospital mortality rates for SAVR and TAVR but statistically significant shorter LOS and lower incidences of in-hospital complications for patients who underwent TAVR compared to SAVR. Patients who received TAVR were also less likely to require skilled nursing support post-discharge. Although this study was not able to consider timing between prior CABG and valve replacement as an additional covariate, the overall results show benefits of TAVR over SAVR and support the trend toward TAVR as the AVR modality of choice.

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