[Moderate aortic stenosis and aorto-coronary bypass]

The presence of aortic stenosis in a patient facing surgical coronary revascularisation is a common situation. A tight aortic stenosis justifies combining aortic valvular replacement with the anticipated bypass. The discovery of a "moderate" aortic stenosis before coronary surgery poses a much more difficult problem. Moderate stenosis equates to aortic area values >0.6 cm2/m2 body area and <1.2 cm2/m2. An estimation of the progression of the stenosis following coronary surgery is fundamental to making the best possible decision but remains very difficult for a given individual. The factors to be taken into account are the aetiology of the stenosis, its severity, the valvular anatomy (calcification), associated coronary artery disease, the age of the patient and the progression of stenosis from one echography to the next. For each patient the risk/benefit ratio of the strategy must therefore be evaluated as much as possible (double procedure at once, or bypass followed by surveillance of the aortic stenosis). In order to do this it is necessary to consider, apart from the stenosis progression factors, the patient's life expectancy and point of view, as well as of course the operative risk (LV function, comorbidity...). Day to day experience shows that the degree of the stenosis is often under-estimated in patients facing coronary surgery, owing to a simple measurement of the gradient. Complete and accurate investigation of the aortic stenosis with Doppler often allows a definitive decision on the most suitable therapeutic approach.