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Impact of simultaneous myocardial revascularization on operative risk, functional result, and survival following
Insights
Coronary artery disease (CAD) is common in patients needing mitral valve replacement (MVR). Simultaneous MVR and coronary artery bypass grafting (CABG) is supported when significant CAD is present, warranting routine angiography.
Area of Science:
- Cardiology
- Cardiac Surgery
- Vascular Medicine
Background:
- Coronary artery disease (CAD) frequently coexists with mitral valve dysfunction.
- Prevalence of CAD varies by mitral valve etiology: 21% in mitral stenosis (MS) and 59% in mitral regurgitation (MR).
- Discordance between angina symptoms and anatomical CAD exists in MS (27%) and MR (36%) patients.
Purpose of the Study:
- To evaluate the impact of CAD and concomitant coronary artery bypass grafting (CABG) on outcomes after mitral valve replacement (MVR).
- To determine the necessity of routine coronary angiography in adults undergoing evaluation for mitral valve disease.
Main Methods:
- Retrospective analysis of 282 patients undergoing MVR with xenograft bioprosthesis.
- Segregation of patients based on mitral dysfunction etiology (rheumatic, myxomatous, ischemic).
- Analysis of operative risk, functional results, and survival based on CAD presence and performance of CABG.
Main Results:
- No significant differences in operative mortality, late angina, late infarction, or survival were observed between patients with or without CAD/CABG, except for a higher perioperative myocardial infarction rate (10% vs 2%) in rheumatic patients with CAD.
- Concomitant CABG was performed in 85-90% of patients with CAD across etiological subgroups.
- Overall arteriographic CAD incidence was 43%.
Conclusions:
- Simultaneous MVR and CABG is recommended for patients with hemodynamically significant CAD.
- Routine coronary angiography is warranted for most adults evaluated for mitral valve disease due to the high incidence of CAD.
Abstract:
A cohort of 282 patients who underwent mitral valve replacement with a xenograft bioprosthesis was strictly segregated according to etiology of mitral dysfunction and analyzed regarding the impact of arteriographic coronary artery disease (CAD) and concomitant coronary artery bypass grafting (CABG) on operative risk, functional result, and survival. CAD was present in 21% of the 122 patients with predominant mitral stenosis (MS) and 59% of the 155 patients with mitral regurgitation (MR); moreover, discordance between the presence of angina and anatomic CAD was found in 27% (33 of 122) of the MS subgroup and 36% (56 of 155) of the MR subgroup. Etiology of the valvular dysfunction was rheumatic in 148 patients, myxomatous degeneration in 83, and ischemic in 32. Within these subgroups, 41 patients (27%), 40 patients (48%), and 32 patients (100%), respectively, had CAD. Of those patients with CAD, 85% of the rheumatic subgroup, 90% of the degenerative subgroup, and 81% of the ischemic subgroup underwent concomitant CABG at the time of valve replacement. Within each subgroup no statistically significant (P greater than 0.05) differences in operative mortality rate, perioperative myocardial infarction rate, incidence of late angina or late infarction, or late actuarial survival were evident when compared on the basis of CAD, and/or CABG, with one exception. The exception was the 10% incidence of perioperative myocardial infarction in the rheumatic subgrohp with coronary disease versus 2% in the rheumatic subgroup without coronary disease (P = 0.05). Within the time constraints of this study (mean follow-up = 2.3 years; maximum follow-up = 5.9 years), these results support simultaneous MVR and CABG when hemodynamically appreciable CAD is found. Moreover, the overall 43% incidence of arteriographic CAD warrants routine coronary angiography in most adults undergoing preoperative catheterization for mitral valvular disease.