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Early results of aortic valve replacement with or without concomitant coronary artery bypass grafting
E Ståhle1, R Bergström, S O Nyström
1Department of Thoracic and Cardiovascular Surgery, University Hospital, Uppsala, Sweden.
Insights
Aortic valve replacement (AVR) outcomes were analyzed. Coronary artery disease increases risk, necessitating AVR before end-stage disease and CABG for significant coronary blockages.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Aortic Valve Replacement
Background:
- Aortic valve replacement (AVR) is a common procedure.
- Concomitant coronary artery disease (CAD) may impact AVR outcomes.
- Optimal surgical strategy for patients with both conditions is debated.
Purpose of the Study:
- To evaluate early outcomes of AVR with and without concomitant coronary artery bypass grafting (CABG).
- To identify predictors of mortality and myocardial injury in these patient groups.
- To inform surgical decision-making for patients with aortic stenosis and CAD.
Main Methods:
- Retrospective review of 962 patients undergoing AVR.
- Comparison of outcomes between isolated AVR (n=659) and AVR + CABG (n=303).
- Multivariate analysis to identify predictors of early mortality and myocardial injury.
Main Results:
- Early mortality was 4.6% for AVR and 5.9% for AVR + CABG.
- Coronary artery stenoses and NYHA class predicted mortality in AVR; number of anastomoses predicted mortality in AVR + CABG.
- Myocardial injury occurred in 11% of AVR and 21% of AVR + CABG patients, predicted by cross-clamp time, year, CAD, and NYHA class.
Conclusions:
- Coronary artery disease increases risk in aortic valve replacement, with or without CABG.
- AVR should be performed before end-stage heart failure (NYHA IV).
- CABG is indicated for significant CAD; limit distal anastomoses in multivessel disease to reduce cross-clamp time.
Abstract:
Early results of aortic valve replacement were reviewed in 962 unselected patients, 659 without concomitant coronary bypass surgery (AVR group) and 303 with combined valve replacement and coronary artery bypass grafting (AVR + CABG). The early (less than 30-day) mortality was 4.6% in the AVR, and 5.9% in the AVR + CABG group. Multivariate analysis showed coronary artery stenoses and NYHA functional class to be independent predictors of early mortality in the AVR group, and the number of distal anastomoses as the strongest predictor in AVR + CABG. The incidence of peroperative technical complications in the cases with fatal outcome was 27% in the AVR and 6% in the AVR + CABG group. The incidence of myocardial injury (new Q wave or evidence of increased enzyme leakage) was 11% in AVR and 21% in AVR + CABG. Independent predictors of postoperative myocardial injury were aortic cross-clamp time, year of surgery, coronary artery stenoses and NYHA class in AVR and aortic cross-clamp time and year of surgery in AVR + CABG. The study suggests that coronary artery disease increases risk in aortic valve replacement with or without CABG. Replacement should be undertaken before endstage of the disease (NYHA IV), with CABG if significant coronary disease is present, and in multivessel disease the number of distal anastomoses should be restricted in order to shorten aortic cross-clamp time.