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Concomitant CABG-procedures in elderly patients undergoing aortic valve replacement. An additional risk factor?
J Litmathe1, U Boeken, P Feindt
1Dept. of Thoracic- and Cardiovascular Surgery, Heinrich-Heine-University, Moorenstrasse 5, 40225 Düsseldorf, Germany. litmathe@med.uni-duesseldorf.de
Insights
For elderly patients undergoing aortic valve replacement (AVR), concomitant coronary artery bypass grafting (CABG) is not associated with poor outcomes. However, bypassing moderate left anterior descending artery (LAD) stenoses improves results in these patients.
Area of Science:
- Cardiovascular Surgery
- Geriatric Cardiology
- Interventional Cardiology
Background:
- Elderly patients undergoing aortic valve replacement (AVR) frequently have coexisting coronary artery disease (CAD).
- The benefit of performing concurrent coronary artery bypass grafting (CABG) alongside AVR in this population remains a subject of debate.
- Some studies suggest isolated AVR may yield better outcomes in elderly patients with CAD.
Purpose of the Study:
- To evaluate the outcomes of AVR with or without concomitant CABG in patients aged 75 years and older.
- To specifically analyze outcomes in elderly patients with known CAD who underwent isolated AVR.
- To determine the impact of bypassing specific coronary artery stenoses on surgical results.
Main Methods:
- Retrospective analysis of 283 patients (≥75 years) undergoing AVR, with or without CABG.
- Patients were divided into AVR (n=166) and AVR+CABG (n=117) groups.
- Subgroup analysis included patients with known CAD undergoing isolated AVR (n=51) versus isolated aortic valve disease (n=115).
Main Results:
- The AVR+CABG group experienced significantly longer mechanical ventilation and ICU stays compared to the AVR group.
- In-hospital mortality and severe postoperative complications were comparable between the two main groups.
- Bypassing moderate left anterior descending (LAD) artery stenoses in the isolated AVR group significantly improved outcomes, unlike stenoses in the right coronary or circumflex arteries.
Conclusions:
- Concomitant CABG is not a predictor of poor surgical outcomes in elderly patients undergoing AVR.
- Bypass grafting for moderate LAD stenoses is crucial for favorable outcomes in elderly patients with AVR and CAD.
- Moderate stenoses in the right coronary or circumflex arteries may be managed conservatively, potentially with secondary catheter intervention.
Objective:
Preoperative coronary angiography in elderly people referred to the hospital for aortic valve replacement (AVR) often shows additional significant stenoses of the coronary arteries (CAD). The benefit of concomitant coronary artery bypass grafting (CABG) in these patients is still discussed controversially. By some authors, an isolated AVR in elderly patients with additional CAD is even described to have a better outcome.
Patients And Methods:
We analyzed 283 patients (> or =75 years), undergoing AVR with or without concomitant CABG-procedures. We particularly analyzed those patients who were operated with an isolated AVR in spite of preoperatively known CAD. There were 166 patients in the AVR group (gr. A) and 117 patients in the AVR+CABG group (gr. AC). 51 of these patients with isolated AVR were preoperatively known to have an additional CAD (stenoses <60%) (gr. A2), whereas 115 patients of group A only suffered from an isolated aortic valve disease (gr. A1).
Results:
Comparing group A and AC, we found a significantly prolonged mechanical ventilation in group AC (22.3+/-5.3 hours vs 10.1+/-1.9 h in gr. A, p<0.05) and a longer stay on the ICU. The incidence of severe postoperative complications and the in-hospital mortality were comparable. In group A2 we could differ between stenoses of the LAD (n=19) and of the right coronary or circumflex artery (n=32). The decision not to bypass a stenosis of the LAD caused a significantly worse outcome of these patients compared to group AC. Ignoring stenoses of the RCA or RCx was not correlated with an impaired postoperative result.
Conclusions:
With our results we could not identify concomitant CABG as a predictor of poor surgical outcome in elderly patients with AVR. We could even show that an additional bypass grafting of moderate stenoses of the LAD is important for a good outcome of these patients. Comparable stenoses in the right coronary or circumflex artery may be ignored with the advantage of a shorter period of intraoperative ischemia and the possibility of a secondary catheter intervention.
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