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Reduction in sudden late death by concomitant revascularization with aortic valve replacement
L S Czer1, R J Gray, M E Stewart
1Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048.
Insights
Coronary artery disease significantly reduces survival after aortic valve replacement, increasing early and late mortality. Myocardial revascularization improves outcomes and reduces sudden death risk without increasing operative risk.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Aortic Valve Replacement
Background:
- Coronary atherosclerosis is a common comorbidity in patients undergoing aortic valve replacement (AVR).
- The impact of concomitant coronary artery disease (CAD) and its treatment on survival after AVR is not fully elucidated.
Purpose of the Study:
- To evaluate the effect of coronary atherosclerosis and myocardial revascularization on early and late survival following isolated AVR.
- To identify predictors of mortality in patients undergoing AVR with and without CAD.
Main Methods:
- Retrospective review of 474 patients who underwent isolated AVR between 1969 and 1984.
- Patients were categorized into three groups: no CAD, coronary artery bypass grafting (CABG), and unbypassed CAD.
- Actuarial survival analysis and multivariate logistic regression were used to assess outcomes.
Main Results:
- Early mortality was higher in patients with CAD (8.2% with CABG, 7.1% unbypassed) compared to those without CAD (2.2%).
- Ten-year survival rates were significantly lower for patients with CAD (41% with CABG, 26% unbypassed) versus no CAD (77%).
- Advanced NYHA class, age, extent of CAD, and lack of cardioplegia predicted early death; CAD and reduced LVEF predicted late death. Revascularization did not increase operative risk.
Conclusions:
- Coexistent coronary atherosclerosis adversely affects both early and late survival after AVR.
- Myocardial revascularization in patients with CAD undergoing AVR does not increase operative risk and significantly reduces late sudden death.
- Strategies including cardioplegia and complete revascularization are recommended for patients with CAD undergoing AVR.
Abstract:
To determine the impact of coronary atherosclerosis and myocardial revascularization on survival after aortic valve replacement, we reviewed our experience with single aortic valve replacement between 1969 and 1984. Of 474 patients (mean age 62 +/- 13 years), 185 (39%) had no associated coronary artery disease, 233 (49%) had coronary artery bypass grafting, and 56 (12%) had unbypassed coronary artery disease. Early (30-day) mortality rates were 2.2%, 8.2%, and 7.1%, respectively (p less than 0.01, coronary disease absent versus present). Actuarial survival rates at 10 years were 77% +/- 4%, 41% +/- 6%, and 26% +/- 11% (p less than 0.001, coronary disease absent versus present), with 1 to 177 months of follow-up (mean 56 +/- 40). Preoperative angina (39%) did not predict the presence of coronary artery disease (61%). Multivariate logistic regression analysis showed that early deaths were associated with advanced preoperative New York Heart Association functional class (p less than 0.001), advanced age (p less than 0.05), more extensive coronary artery disease (p less than 0.05), and lack of cardioplegic myocardial protection (p less than 0.05). Complete revascularization did not increase operative risk when coronary artery disease was present (early mortality 6.8%, p = not significant). Late deaths were strongly associated with the presence of coronary artery disease (p less than 0.001) and reduced left ventricular ejection fraction (less than or equal to 55%, p less than 0.01). Late cardiac mortality was most commonly attributable to sudden death (30/71, 42%), especially in the unbypassed coronary disease cohort (9/14, 64%). The actuarial rate of freedom from sudden death at 10 years was 52% +/- 17% in the unbypassed coronary artery disease group (p = 0.009), compared with 90% +/- 3% and 91% +/- 3% in the revascularized and no coronary disease patients, respectively. Thus, coexistent coronary atherosclerosis has a detrimental impact on early and late survival after aortic valve replacement. Revascularization does not increase operative risk when associated coronary artery disease is present and significantly reduces the occurrence of late sudden death. Strategies that minimize operative risk when associated coronary artery disease is present include use of cardioplegia and complete revascularization.