Should the Aortic Valve Be Replaced in Patients with Mild Aortic Stenosis Admitted for Coronary Surgery?

Abstract

Background: The question whether the aortic valve in patients with mild aortic stenosis undergoing coronary artery bypass grafting (CABG) should be replaced or left alone is still controversial.

Methods: Between 01/1995 and 03/2004, 38 patients (30 male, 8 female, mean age 70.9 ± 7.8 years) required redo AVR 7.1 ± 4.8 years after primary CABG, while 202 patients (125 male, 77 female, mean age 72.7 ± 7.8 years) underwent combined AVR and CABG (1.9 ± 0.8 grafts/patient). To evaluate the different approaches, the data of the redo-AVR group were compared with the data of a propensity-score matched group of AVR + CABG patients.

Results: All patients survived the procedure; the 30-day survival was 94.7 % in both groups. The 1- and 5-year survival rates were 94.7 % and 83.8 % in the AVR after CABG group, and 94.7 % and 86.9 % in the AVR + CABG group, respectively. The late mortality was 28.9 % in the AVR after CABG and 25 % in the AVR + CABG group. Statistically, significant differences regarding perioperative mortality and morbidity could not be detected, neither with nor without propensity score analysis.

Conclusion: Combined AVR and CABG in patients with coronary artery disease and mild to moderate aortic stenosis seems advisable in an institution with an equally low perioperative risk for both procedures, because the patient will need only one surgical procedure instead of undergoing surgery with all the associated risks twice.

Key words

coronary bypass surgery - aortic valve replacement - aortic valve stenosis - reoperation

References

• 1 ACC/AHA . 2006 Guidelines for the management of patients with valvular heart disease.  Circulation. 2006;  114 84-231
• 2 Otto C M, Burwash I G, Legget M E, Munt B I, Fujioka M, Healy N L, Kraft C D, Miyake-Hull C Y, Schwaegler R G. Prospective study of asymptomatic valvular aortic stenosis.  Circulation. 1997;  95 2262-2270
• 3 Faggiano P, Ghizzoni G, Sorgato A, Sabatini T, Simoncelli U, Gardini A, Rusconi C. Rate of progression of valvular aortic stenosis in adults.  Am J Cardiol. 1992;  70 229-233
• 4 Gillinov A M, Garcia M L. When is concomitant aortic valve replacement indicated in patients with mild to moderate stenosis undergoing coronary revascularization?.  Curr Cardiol Rep. 2005;  7 101-104
• 5 Kurlansky P A, Williams D B, Traad E A, Carillo R G, Zucker M, Ebra G. Surgical management of aortic valve disease in elderly patients with and without coronary artery disease: influence on quality of life.  J Cardiovasc Surg (Torino). 2007;  48 215-226
• 6 David T E, Ivanov J, Armstrong S, Feindel C M, Cohen G. Late results of heart valve replacement with the Hancock II Bioprosthesis.  J Thorac Cardiovasc Surg. 2001;  121 268-278
• 7 Zellner J L, Kratz J M, Crumbley I IIAJ, Stroud M R, Bradley S M, Sade R M, Crawford F A. Long-term experience with the St. Jude Medical valve prosthesis.  Ann Thorac Surg. 1999;  68 1210-1218
• 8 Edmunds L H, Clark R E, Cohn L H, Grunkemeier G L, Miller C, Weisel R D. Guidelines for reporting morbidity and mortality after cardiac valvular operations.  Ann Thorac Surg. 1996;  62 932-935
• 9 Hochrein J, Lucke J C, Harrison K, Bashore T M, Wolfe W G, Jones R H, Lowe J E, White W D, Glower D D. Mortality and need for reoperation in patients with mild-to moderate asymptomatic aortic valve disease undergoing coronary artery bypass graft alone.  Am Heart J. 1999;  138 791-797
• 10 Hilton T C. Aortic valve replacement for patients with mild to moderate aortic stenosis undergoing coronary artery bypass surgery.  Clin Cardiol. 2000;  23 141-147
• 11 Sundt T M, Murphy S F, Barzilai B, Schuessler R B, Mendeloff E N, Huddleston C B, Pasque M K, Gay W A. Previous coronary artery bypass grafting is not a risk factor for aortic valve replacement.  Ann Thorac Surg. 1997;  64 651-658
• 12 Collins J J, Aranki S F. Management of mild aortic stenosis during coronary artery bypass grafting.  J Card Surg. 1994;  9 (Suppl) 145-147
• 13 Smith I VWT, Ferguson B, Ryan T, Landolfo C K, Peterson E D. Should coronary artery bypass graft surgery patients with mild or moderate aortic stenosis undergo concomitant aortic valve replacement?.  J Am Coll Cardiol. 2004;  44 1241-1247
• 14 Yoshida K, Matsumoto M, Sugita T, Nishizawa J, Matsuyama K, Tokuda Y, Matsuo T. Management of asymptomatic aortic stenosis in patients undergoing coronary artery bypass grafting.  Circ J. 2003;  67 199-202
• 15 Verhoye J P, Merlicco F, Sami I M, Cappabianca G, Lecouis H, Corbineau H, Langanay T, Leguerrier A. Aortic valve replacement for aortic stenosis after previous coronary artery bypass grafting: could early reoperation be prevented?.  J Heart Valve Dis. 2006;  15 474-478
• 16 Eitz T, Kleikamp G, Minami K, Körfer R. The prognostic value of calcification and impaired valve motion in combined aortic stenosis and coronary artery disease.  J Heart Valve Dis. 2002;  11 713-718
• 17 Phillips B J, Karavas A N, Aranki S F, Cohn L H, Rawn J D, Mihajevic T, Byrne J G. Management of mild aortic stenosis during coronary artery bypass surgery: an update, 1992–2001.  J Card Surg. 2003;  18 507-511
• 18 Karagounis A, Valencia O, Chandrasekaran V, Smith J, Brecker S, Jahangiri M. Management of patients undergoing coronary artery bypass graft surgery with mild to moderate aortic stenosis.  J Heart Valve Dis. 2004;  13 369-373
• 19 Gummert J F, Funkat A, Beckmann A, Hekmat K, Ernst M, Krian A. Cardiac surgery in Germany during 2005.  Thorac Cardiovasc Surg. 2006;  54 362-372