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Management of asymptomatic mild aortic stenosis during coronary artery operations
A C Fiore1, M T Swartz, K S Naunheim
1Division of Cardiothoracic Surgery, St. Louis University Health Sciences Center, Missouri, USA.
Insights
Performing aortic valve replacement (AVR) after coronary artery bypass grafting (CABG) increases operative mortality. However, long-term survival remains similar, indicating progression of aortic stenosis necessitates later AVR in some patients.
Area of Science:
- Cardiovascular Surgery
- Cardiac Valve Disease
Background:
- Management of asymptomatic mild aortic stenosis during coronary artery bypass grafting (CABG) is debated.
- Retrospective analysis compares outcomes of staged versus simultaneous CABG and aortic valve replacement (AVR).
Purpose of the Study:
- To compare operative morbidity and mortality between patients undergoing AVR after CABG versus those receiving simultaneous CABG and AVR.
- To assess long-term survival and progression of aortic stenosis in patients with mild stenosis at the time of CABG.
Main Methods:
- Retrospective analysis of 28 patients (Group A) with AVR after CABG and 175 patients (Group B) with simultaneous CABG and AVR.
- Groups were matched for key demographic and clinical characteristics.
Main Results:
- Patients undergoing AVR after CABG experienced longer cross-clamp and ischemic times, with a twofold increase in operative mortality.
- No significant difference in 10-year actuarial survival was observed between the groups.
- Aortic valve area decreased by 0.05 mm²/year in patients awaiting reoperation.
Conclusions:
- While the operative mortality and morbidity of a second procedure for AVR are substantial, 10-year survival is comparable.
- Progression of aortic stenosis in a subset of patients initially presenting with mild stenosis during CABG will necessitate future AVR.
Background:
Management of asymptomatic mild aortic stenosis at the time of coronary artery bypass grafting (CABG) remains controversial. We have retrospectively analyzed a cohort of patients requiring aortic valve replacement (AVR) subsequent to CABG and compared their operative morbidity and mortality with that of a group receiving CABG and AVR simultaneously at the first operation.
Methods:
Analysis is drawn from 28 patients who required AVR 8 +/- 4 years subsequent to CABG (group A) and 175 patients receiving AVR along with CABG at the primary operation (group B). Groups were similar with respect to age, sex, risk factors for cardiac disease, extent of coronary artery disease, left ventricular function, New York Heart Association class, aortic valve area, number of grafts, and size of prosthesis inserted.
Results:
Patients having AVR subsequent to CABG had a significantly prolonged aortic cross-clamp time and global myocardial ischemic time and incurred a twofold increase in operative mortality. The actuarial survival at 10 years was not significantly different between cohorts. In the 28 patients in group A, the aortic valve area during the period between operations decreased 0.05 mm2/y.
Conclusions:
The operative mortality and morbidity of a second operation for AVR is high, but there is no significant difference in survival at 10 years. In at least a portion of patients having mild aortic stenosis at the time of CABG there will be progression of the stenosis necessitating reoperation at a later date.