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: 4.46).
11/1999; 138(4 Pt 1):791-7. DOI: 10.1016/S0002-8703(99)70198-5
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.
Available from: Maurice E Sarano
- "Severe AS is uniformly considered a Class I indication for aortic valve replacement (AVR) in patients undergoing CABG (level of evidence 'C') . 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       . 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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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.
We identified 312 patients who underwent isolated CABG between 1993 and 2006 with mild or moderate AS [aortic valve area (AVA) 1-2 cm(2)], and matched them to patients undergoing CABG alone during the same period with similar characteristics but without AS (AVA >2 cm(2)). Long-term survival after CABG and its determinants were analysed using Cox proportional hazards models with AVR as a time-dependent covariate.
Late survival was lower in patients with untreated moderate AS (12 years 23 ± 5.1%) versus mild (42 ± 3.8%) or no AS (38 ± 3.3%) (P = 0.01). Adjusting for age, ejection fraction, heart failure, creatinine, diabetes, peripheral vascular disease (PVD) and interval AVR, moderate AS independently predicted higher mortality [hazard rate (HR) 2.01, 95% confidence interval (CI) 1.49-2.73; P < 0.001]; whereas incremental risk was insignificant for patients with mild AS (HR 1.09, 95% CI 0.85-1.66; P = 0.33). Further stratification showed that highest late postoperative mortality occurred with an AVA of 1-1.25 cm(2) (adjusted HR 2.45, 95% CI 1.57-3.82; P < 0.001), while risk was intermediate with an AVA of 1.25-1.5 cm(2) (HR 1.83, 95% CI 1.28-2.61; P = 0.001).
Untreated moderate AS is an independent determinant of excess late mortality following isolated CABG, and mortality risk increases with decreasing AVA. Those with moderate-to-severe AS (AVA 1-1.25 cm(2)) have more than 2-fold greater long-term mortality compared with those without AS. These data define AS severity thresholds for clinical trials aimed at defining whether valve intervention might mitigate this risk.
Available from: Joon Bum Kim
- "It is broadly accepted that AVR should be performed in conjunction with CABG if aortic stenosis is severe or if the patient has symptoms. However, controversy exists regarding the treatment of asymptomatic patients with mild or moderate stenosis [17,18]. A recent study showed that AVR at the time of CABG for mild or moderate aortic stenosis appeared to convey a survival advantage on patients with moderate aortic stenosis but not on those with mild aortic stenosis [11,19,20]. "
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ABSTRACT: We evaluated the surgical results and predictors of long-term survival in patients who underwent coronary artery bypass grafting (CABG) at the time of an aortic valve replacement (AVR) due to aortic stenosis.
Between January 1990 and December 2009, 183 consecutive patients underwent CABG and concomitant aortic valve replacement for aortic stenosis. The mean follow-up period was 59.8±3.3 months and follow-up was possible in 98.3% of cases. Predictors of mortality were determined by Cox regression analysis.
There were 5 (2.7%) in-hospital deaths. Follow-up of the in-hospital survivors documented late survival rates of 91.5%, 74.8%, and 59.6% at 1, 5, and 10 postoperative years, respectively. Age (p<0.001), a glomerular filtration rate (GFR) less than 60 mL/min (p=0.006), and left ventricular (LV) mass (p<0.001) were significant predictors of mortality in the multivariate analysis.
The surgical results and long-term survival of aortic valve replacement with concomitant CABG in patients with aortic stenosis and coronary artery disease were acceptable. Age, a GFR less than 60 mL/min, and LV mass were significant predictors of mortality.
Available from: ejcts.oxfordjournals.org
- "The management of coexisting coronary artery and mild to moderate aortic valve disease is a very controversial subject. The advocates of aortic valve replacement at the time of CABG argue that patients with mild aortic valve disease invariably develop worsening symptoms due to the progression of valve disease in a few years' time [2,3,12], and they recommend simultaneous AVR for mild aortic valve disease on the basis of the high operative risks of repeat surgery for aortic valve disease following initial CABG. Fiore et al.  reported an 18% operative mortality in 28 patients who underwent AVR following initial CABG as opposed to 9.1% in a group that underwent combined AVR and CABG. "
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ABSTRACT: The long term survival of patients with mild to moderate aortic valve disease who do not have valve replacement at the time of coronary artery bypass grafting (CABG) is unknown. Therefore we have reviewed our experience with such patients.
We reviewed the medical records of consecutive patients between June 1978 and December 1996, and identified 40 patients with mild to moderate aortic valve disease, who underwent CABG, without valve replacement (study group). Mean preoperative aortic gradient was 34 mmHg and mean intraoperative gradient 20 mmHg. Eleven patients underwent valve inspection, and an equal number, underwent valve repair. The records of 61 other patients with severe aortic valve disease, who underwent concomitant aortic valve replacement (AVR) and CABG (control group), were also reviewed.
Survival was significantly better in the control group. Eleven patients (27.5%) in the study group underwent reoperation for AVR, with no operative mortality. Multivariate analysis confirmed valve replacement at initial CABG to be the only predictor of survival (beta=0.586,P=0.038) Preoperative gradient <40 mmHg, intraoperative gradient <20 mmHg, age over 70, sex, aortic stenosis and valve pathology did not predict survival in the study group.
Patients with mild to moderate aortic valve disease undergoing coronary artery bypass grafting may be best served by valve replacement, rather than repair, inspection or no procedure.
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