Article

Mortality and need for reoperation in patients with mild-to-moderate asymptomatic aortic valve disease undergoing coronary artery bypass graft alone.

Department of Medicine, Duke University Medical Center, Durham, NC, USA.
American Heart Journal (Impact Factor: 4.56). 11/1999; 138(4 Pt 1):791-7. DOI: 10.1016/S0002-8703(99)70198-5
Source: PubMed

ABSTRACT Patients presenting for coronary artery bypass graft (CABG) surgery may have concurrent asymptomatic aortic stenosis (AS) or aortic insufficiency (AI). This retrospective study was performed to evaluate outcomes in patients with aortic valve disease undergoing CABG with or without aortic valve replacement (AVR).
Study groups included 414 patients undergoing combined AVR and CABG (AVR-CABG group) and 62 patients with asymptomatic mild-to-moderate AS, AI, or both undergoing CABG but not AVR (CABG group). End points included 30-day mortality rate, time to cardiac mortality, time to all-cause mortality, and time to aortic valve reoperation. Reoperation refers to surgery for replacement of the native aortic valve in the CABG group or replacement of the prosthetic aortic valve in the AVR-CABG group. Important patient characteristics affecting outcomes were determined by using Cox proportional-hazard analysis. These variables were then included in multivariable analyses by using logistic regression analysis and Cox proportional-hazard modeling to compare outcomes between each patient group.
No difference was seen in any of the mortality end points between the CABG group and the AVR-CABG group after controlling for significant differences between the groups. However, the need for reoperation for AVR was significantly higher for the CABG group than the AVR-CABG group. For patients followed for up to 6 years, the estimated need for aortic valve reoperation was 24.3% in the CABG group versus 3% in the AVR-CABG group.
On the basis of these results, patients with asymptomatic AS or AI should be considered for AVR at the time of CABG.

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    • "Severe AS is uniformly considered a Class I indication for aortic valve replacement (AVR) in patients undergoing CABG (level of evidence 'C') [6]. In contrast, results and recommendations of studies investigating management of 'less-than-severe' AS at the time of CABG have been conflicting, giving rise to inconsistent practices and variably interpreted surgical guidelines [4] [5] [6] [7] [8] [9] [10]. To date, reports examining this question (i) have studied heterogeneous cohorts, (ii) introduced selection bias by comparing patients with and without AVR at CABG, and (iii) have not clearly defined whether less-than-severe AS, if untreated at the time of CABG, confers a deleterious impact upon long-term prognosis . "
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    ABSTRACT: Aortic valve replacement (AVR) for severe aortic valve stenosis (AS) is a Class I indication at the time of coronary artery bypass grafting (CABG). Management of less-than-severe AS in patients undergoing CABG is uncertain however, because the thresholds at which untreated AS impacts long-term outcome are unclear.
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    ABSTRACT: The presence of moderate aortic valve (AV) lesions associated with other pathologies that require surgery presents a problem since ignoring or replacing the valve seems unsatisfactory. AV repair can be an attractive alternative if shown to perform satisfactory. To evaluate this possibility, all consecutive AV patients who underwent operation between July 1988 and July 1999 were reviewed. Out of 1764 AV patients, 239 (14%) underwent repair and 86 (study group) had moderate lesions associated with mitral (73), tricuspid (33), coronary disease (5) and others (8). Mean age was 28 years (range 2--66); 78% were rheumatic, 71% were in sinus rhythm and 71% in NYHA class III--IV. There were seven hospital deaths (8%) and three patients were lost to follow-up (95% complete). Late mortality was 8% and 10-year actuarial survival was 86 +/- 4.5% (excluding hospital mortality). There were four (5%) embolic events (actuarial freedom 94 +/- 3.5%). Twenty-one patients required reoperation with two mortalities. The AV was not touched in five patients. In the remaining 16, the AV was replaced. Only one patient had isolated AV replacement while in all others, additionally, the mitral, tricuspid, or both required surgery. All reoperated patients had rheumatic etiology. Actuarial freedom from AV dysfunction at 8 years was 68 +/- 7.5%. Repair of associated moderate AV lesion is worth considering even in a predominantly young rheumatic population.
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