Background:
The presence of coronary artery disease (CAD) in women undergoing a Transcatheter Aortic Valve Implantation (TAVI) is associated with a worse outcome compared to those without CAD. Whether a complete revascularization and hereby outcome is achieved similarly in female patients treated with an interventional (PCI plus TAVI) or surgical (CABG plus SAVR) treatment strategy is still unclear.

Purpose:
This study aims to analyze the extent of revascularization in terms of SyntaxScore and to evaluate the differences in 30-days (short-term) and one-year and three-years (intermediate term) mortality in women with CAD and AS undergoing a surgical or catheter-based treatment.

Methods:
All patients were enrolled at one tertiary center in Germany between 2016 and 2019. Initially the surgical group consisted of 932 patients and the interventional cohort contained 360 patients as a result of setting a maximum time interval of 3 months between PCI and TAVI. CABG+SAVR and PCI+TAVI cohorts were compared by using a propensity score analysis. Age, left ventricular function, EuroSCORE II and degree of CAD served as matching parameters. Finally, the matched female cohort consisted of 114 patients (57 patients treated interventionally, 57 treated surgically). Syntax Score was measured before and after the treatment. As a primary endpoint all-cause mortality was analyzed at 30 days, one and three years after the procedure. 

Results: Median age was 80 years both in PCI+TAVI and CABG+SAVR patients (p=0.298). The interventional and surgical group represented a moderate to high-risk population (EuroScore II in PCI+TAVI: 4.39 [2.83-8.82] vs 6.18 [3.43-8.6] in CABG+SAVR (p=0.279) and showed no significant difference in median pre-interventional/preoperative SyntaxScore I (PCI+TAVI: 16.00 [9-26.5] vs CABG+SAVR: 18 [9.5-25.5]; p=0.719). In the interventional group coronary physiology was measured more frequently (6.8% vs 1.8%, p=0.024). The presence of an aortoostial lesion, heavy calcification and a length of the lesion >20mm differed not significantly between PCI+TAVI and CABG+SAVR before therapy (PCI+TAVI vs CABG+SAVR: 11.1% vs 13.0%, p=0.581; 60.5% vs 55.1%, p=0.289; 20.4% vs 25.1%, p=0.316). The main stem as target lesion was present in both groups with no significant difference (PCI+TAVI vs CABG+SAVR: 8.8% vs 19.3%, p=0.106).
Of interest, median residual SyntaxScore I was significantly higher in PCI+TAVI than in CABG+SAVR (5.0 [0.0-13.0] vs 0.0 [0.0-8.5], p=0.03).
There was no significant difference in 30-days, 1-year and 3-years mortality between the interventional and surgical group (PCI+TAVI vs CABG+SAVR: 3.5% vs 8.8%, p=0.242; 10.5% vs 14%, p=0.568; 22.8% vs 15.8%, p=0.342).

Conclusion:
Female patients with AS and CAD with low SyntaxScore undergoing a surgical revascularization and aortic valve replacement reach a more complete revascularization compared to those treated interventionally. Nevertheless, this fact seems to have no influence on short and intermediate term mortality.