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Management of mild aortic stenosis during coronary artery bypass graft surgery
1Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts 02115.
Insights
Mild aortic stenosis may rapidly progress to severe symptomatic disease after coronary artery bypass graft surgery. This suggests considering aortic valve replacement during CABG even for mild cases.
Area of Science:
- Cardiology
- Cardiac Surgery
- Valvular Heart Disease
Background:
- Patients with coronary artery disease often have coexistent valvular disease.
- The management of mild-to-moderate aortic stenosis (AS) in patients undergoing coronary artery bypass graft (CABG) surgery is not well-defined.
Purpose of the Study:
- To investigate the progression of mild-to-moderate aortic stenosis in patients who previously underwent CABG surgery.
- To determine if aortic valve replacement (AVR) should be considered during CABG for mild AS.
Main Methods:
- Retrospective review of 44 patients who underwent AVR for severe AS between 1975 and 1992.
- Analysis of AS severity (transvalvular gradients, aortic valve area) at the time of prior CABG and subsequent AVR.
Main Results:
- Patients previously diagnosed with mild AS at CABG developed severe AS requiring AVR within a median of 68 months.
- Symptomatic severe AS developed in 16% by 3 years, 45% by 4 years, and 75% by 5 years post-CABG.
- Transvalvular gradients increased significantly, and aortic valve areas decreased over time after CABG.
Conclusions:
- Mild, asymptomatic aortic valve disease can progress rapidly to severe, symptomatic AS after CABG.
- This progression may occur before recurrent coronary symptoms, suggesting consideration for AVR during CABG even in mild AS cases.
Abstract:
A small proportion of patients with significant coronary artery disease referred for coronary artery bypass graft (CABG) surgery have coexistent congenital or valvular disease that, if isolated, would be inadequately severe to justify surgery. While there is general agreement that CABG should be performed for obstruction of major epicardial arteries even without ischemic symptoms in patients having aortic valve replacement (AVR) for aortic stenosis (AS), there has been little or no consideration of whether "mild-to-moderate" AS should be treated by valve repair or AVR at the time of CABG. Between 1975 and 1992, we performed AVR for symptoms or signs of severe AS without significant ischemia on 44 patients with previous CABG. None of these patients were considered to have serious AS at the time of CABG surgery 8 to 164 months (68 months) previously. At aortic surgery, ages ranged from 52 to 83 years (73); 38% were female. In 20 patients with available data, transvalvular gradients ranged from 0 to 23 (12) mmHg at CABG and 29 to 95 (62) mmHg at AVR. Aortic valve areas at CABG ranged from 0.9 to 2.2 (1.5) cm2 and at AVR ranged from 0.3 to 1.7 (0.7) cm2. Appearance of symptoms and signs of severe AS occurred in 16% by 3 years; 45% by 4 years; and 75% by 5 years after CABG surgery. These data observations suggest that mild, asymptomatic valve deformity may progress to symptomatic, hemodynamically severe AS within a short time after CABG surgery, well before recurrent symptoms of coronary obstructive disease.(ABSTRACT TRUNCATED AT 250 WORDS)