Combined valve replacement and myocardial revascularization

Aortic valve replacement for patients with mild to moderate aortic stenosis undergoing coronary artery bypass surgery

Aortic valve replacement (AVR) is not normally recommended in asymptomatic patients, even if aortic stenosis is severe. However, as the population ages, an increasing number of patients with mild or moderate aortic stenosis will require coronary artery bypass grafting (CABG). In these cases, risk of "prophylactic" AVR needs to be weighed against risks of subsequent worsening of the mildly or moderately diseased aortic valve. If unoperated, aortic stenosis will worsen at an average of 6-8 mmHg per year (-0.1 cm2/year valve area), and one-quarter of such patients will require late AVR with a high operative mortality (14-24%). If AVR is performed at the time of CABG, operative risk is increased only slightly (from 1-3% to 2-6%), as are late mortality (1-2% per year) and morbidity (1-2% per year), mainly from hemorrhagic complications. Intrinsic gradients of most prosthetic valves are sufficiently low that even patients with low aortic valve gradients are likely to derive hemodynamic benefit from AVR. Thus, if there is a measurable (>20-25 mmHg) gradient across the aortic valve in a patient who requires CABG, the patient is at considerable risk for developing symptomatic aortic stenosis prior to reaching the end of expected benefit from CABG; in this case AVR should be considered. It may be reasonable in patients with very mild gradients (<25 mmHg) to defer aortic valve surgery; however, it should be noted that aortic stenosis progression is generally more rapid when the initial gradient is small.

Interaction of age and coronary disease after valve replacement: implications for valve selection

The interaction of patient age and the presence of coronary artery disease (CAD) and its influence on survival were examined in 3,644 patients undergoing either aortic (AVR) or mitral (MVR) valve replacement with or without coronary artery bypass grafting (CABG) between 1974 and 1991. Emergency procedures were performed much more frequently in those undergoing MVR and CABG than in those undergoing AVR and CABG (18.8% and 6.7%, respectively). The adverse effect of CAD on median survival for patients of all ages undergoing either AVR or MVR was statistically significant (AVR without CAD 11.8 versus 8.7 years with CAD; MVR without CAD 12.7 versus 7.3 years with CAD; p < 0.0001). Survival in patients younger than 70 years without CABG who underwent either AVR or MVR was quite good (< 60 years: AVR, > 14 years; MVR, 15.4 years; 60 to 69 years: AVR, 10.4 years; MVR, 11.4 years). The most profound effect of CAD on patient survival after valve replacement was observed in patients 60 to 69 years of age who underwent MVR, in whom the median survival without CABG was 11.4 years versus 5.5 years with CABG (p < 0.0001). An emergency operative status was associated with a reduced early and late survival for those patients undergoing MVR, particularly those with CAD. By relating the Cox proportional hazard models for valve survival to patient survival, we found that, in those patients 70 years and older with and without CAD who underwent either AVR or MVR, the median patient survival was reduced sufficiently (5.5 versus 8.1 years) to justify use of a bioprosthetic valve.(ABSTRACT TRUNCATED AT 250 WORDS)

Valve surgery combined with myocardial revascularisation. Report of 62 cases

Combined valvular and coronary bypass surgery was performed in 1984-1988 in 62 patients. Their age range at operation was 38-75 (mean 59) years and more than 90% were in NYHA class III or IV. Valve replacement was performed in 55 cases--mitral in 13, aortic in 33, tricuspid in one and combined valve procedures in eight cases--and valvular correction in seven cases. The patients also received a total of 92 coronary artery grafts (1-4/patient, mostly as single grafts). The hospital mortality was 3% and there were two late deaths. Follow-up was 100% complete 2-52 (mean 22) months after surgery, and more than 90% of the survivors were improved.

Double valve replacement and coronary artery bypass in a patient with chronic osteomyelitis

Implantation of a prosthetic heart valve is generally contra-indicated in the presence of infection. A 68-year-old man with chronic osteomyelitis underwent successful double valve replacement, combined with coronary artery bypass, after his draining osteomyelitic fistula was controlled with antibiotics. During the 39 months since surgery, he has shown no sign of paravalvular leakage or infectious complications.

Factors influencing early and late survival in patients with combined mitral valve replacement and myocardial revascularization and in those with isolated replacement

During a 5 1/2-year period, 251 patients underwent mitral valve replacement (MVR) at our institution: 76 had combined MVR and coronary artery bypass grafting (CABG), and 175 without major coronary artery disease (CAD) had isolated MVR. In-hospital mortality for MVR + CABG was 13.2% (10/76); it was 8.6% (6/70) when patients with preoperative mechanical support were excluded, 7.9% (5/63) for elective operations, and 8.2% (5/61) for nonischemic mitral disease. Overall, in-hospital mortality for isolated MVR was 6.3% (11/175); it was 4.4% (7/161) excluding patients requiring mechanical support and 3.1% (5/157) for elective operations. Of a host of clinical characteristics in patients with MVR +CABG, few were found to influence in-hospital mortality: age greater than 60 years, degree of incapacitation (New York Heart Association Functional Class IV), previous history of myocardial infarction or congestive heart failure, cardiac enlargement (cardiothoracic index greater than 50%), and ischemic mitral disease (33.3% in-hospital mortality; p less than 0.05). Of the invasive variables, only one influenced in-hospital mortality: wall motion score greater than 10 (31.6% in-hospital mortality; p less than 0.01). Of the operative variables studied, the number of grafts (3 or more: 33.3% in-hospital mortality; p less than 0.05), the need for mechanical support (47.4% in-hospital mortality; p less than 0.0001), and emergency operation (38.5% in-hospital mortality; p less than 0.005) had a significant effect on mortality. The type of mitral lesion, the type of prosthesis, the extent of CAD or the completeness of revascularization, the presence of pulmonary hypertension, and atrial fibrillation appeared to have no influence.(ABSTRACT TRUNCATED AT 250 WORDS)

Preoperative risk assessment in cardiac surgery: comparison of predicted and observed results

In the present climate of quality-assurance policies, rigorous requirements for informed consent, and a constantly changing patient population, a system of preoperative risk assignment and postoperative correlation was developed to monitor and evaluate surgical performance. Patients were categorized by operation, priority (emergent, urgent, elective), New York Heart Association Functional Class, and risk. Risk was assigned before operation using data from the Coronary Artery Surgery Study (CASS) and the recent literature. Data were collected by a full-time data manager and were stored and analyzed by computer. From January 1, 1984, to July 1, 1985, 1,303 patients underwent operation for acquired disease. This group included 913 patients undergoing isolated primary coronary artery bypass grafting (CABG). The comparison of predicted and observed results showed: (Table: see text). For patients undergoing isolated primary CABG, the elective group had an operative mortality of 0.6% (2/329); the urgent group, 1.1% (5/450); and the emergent group, 5.2% (7/134). Preoperative risk assignment is an effective method of quality assurance. Female sex and age older than 60 years, which predicted an operative mortality of 2 to 5% in the CASS study and other recent series, did not predict a similar risk in our series.

Combined valve replacement and coronary bypass surgery. Results in 127 operations stratified by surgical risk factors

The results of 127 operations with both valve replacement and coronary bypass were compared with all 5,053 operations involving coronary bypass performed from August 1972 through June 1985. Both groups were stratified by the number of risk factors (age over 70 years, bad ventricle, extensive endarterectomy, and reoperation). Compared with all bypass operations, valve replacement had no effect on surgical mortality except in the group at highest risk. Conversely, valve replacement was associated with reduced late survival in all but those at highest risk. Results with tissue valves were better than with mechanical, but statistical significance was lacking. Relief of angina was equal. Ischemic mitral insufficiency continues to be the greatest challenge, with 46 percent five-year survival. We conclude that combined valve replacement and bypass surgery can be performed successfully, even in the patients at higher risk; however, this operation should be performed only by teams with demonstrated success in surgically treating advanced coronary artery disease.

Mitral valve replacement combined with myocardial revascularization: early and late results for 300 patients, 1970 to 1983

Of 300 consecutive patients undergoing primary operation for mitral valve replacement combined with coronary bypass grafting, 22 (7.3%) died in-hospital. Multivariate testing of preoperative and operative descriptors identified radiographic cardiac enlargement, preoperative paced rhythm or atrial fibrillation, 70% or more left main coronary obstruction, and serum bilirubin of more than 2 mg% as factors associated with an increase in in-hospital mortality. Follow-up of the 278 hospital survivors (mean interval 48 months, range 2 to 165 months) documented survival of 85%, 66%, and 31% and an event-free survival of 65%, 46%, and 21% at 2, 5, and 10 postoperative years, respectively. Cox proportional-hazard regression models of late risk implicated in-hospital ventricular arrhythmias, left ventricular dysfunction, and rheumatic or ischemic causes of mitral valve disease in decreasing long-term survival. In addition, patients with bioprostheses without warfarin anticoagulation had better survival and event-free survival than those with bioprostheses taking warfarin and those with mechanical prostheses with or without warfarin.