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McHugh S, Allaham H, Chahal D, Gupta A. Coronary Artery Revascularization in Patients Undergoing Transcatheter Aortic Valve Replacement. Cardiol Clin 2024; 42:333-338. [PMID: 38910018 DOI: 10.1016/j.ccl.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Patients with concomitant severe aortic stenosis and significant coronary artery disease present a diagnostic and therapeutic challenge in clinical practice. There are no clear-cut guidelines as to the timing of revascularization in these patients who are referred for transcatheter aortic valve replacement (TAVR). This article aims to show that in patients without high-grade proximal coronary artery disease, revascularization after TAVR is safe, feasible, and practical. Additionally, the use of preoperative TAVR computed tomographic angiography might be used in both intermediate and high-risk patients rather than invasive coronary angiography to assess for significant proximal coronary artery disease to help guide the timing of revascularization.
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Affiliation(s)
| | | | - Diljon Chahal
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Anuj Gupta
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Masraf H, Sef D, Chin SL, Hunduma G, Trkulja V, Miskolczi S, Velissaris T, Luthra S. Long-Term Survival among Octogenarians Undergoing Aortic Valve Replacement with or without Simultaneous Coronary Artery Bypass Grafting: A 22-Year Tertiary Single-Center Experience. J Clin Med 2023; 12:4841. [PMID: 37510956 PMCID: PMC10381828 DOI: 10.3390/jcm12144841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/12/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The impact of concomitant coronary artery bypass grafting (CABG) on aortic valve replacement (AVR) in octogenarians is still debated. We analyzed the characteristics and long-term survival of octogenarians undergoing isolated AVR and AVR + CABG. METHODS All octogenarians who consecutively underwent AVR with or without concomitant CABG at our tertiary cardiac center between 2000 and 2022 were included. Patients with redo, emergent, or any other concomitant procedures were excluded. The primary endpoints were 30-day and long-term survival. The secondary endpoints were early postoperative outcomes and determinants of long-term survival. Univariable and multivariable logistic regression analyses were performed to identify independent predictors of 30-day mortality, and Cox regression analysis was performed for predictors of adverse long-term survival. RESULTS A total of 1011 patients who underwent AVR (83.0 [81.0-85.0] years, 42.0% males) and 1055 with AVR + CABG (83.0 [81.2-85.4] years, 66.1% males) were included in our study. Survival at 30 days and at 1, 3, and 5 years in the AVR group was 97.9%, 91.5%, 80.5%, and 66.2%, respectively, while in the AVR + CABG group it was 96.2%, 89.6%, 77.7%, and 64.7%, respectively. There was no significant difference in median postoperative survival between the AVR and AVR + CABG groups (7.1 years [IQR: 6.7-7.5] vs. 6.6 years [IQR: 6.3-7.2], respectively, p = 0.21). Significant predictors of adverse long-term survival in the AVR group included age (hazard ratio (HR): 1.09; 95% CI: 1.06-1.12, p < 0.001), previous MI (HR: 2.08; 95% CI: 1.32-3.28, p = 0.002), and chronic kidney disease (HR 2.07; 95% CI: 1.33-3.23, p = 0.001), while in the AVR + CABG group they included age (HR: 1.06; 95% CI: 1.04-1.10, p < 0.001) and diabetes mellitus (HR: 1.48; 95% CI: 1.15-1.89, p = 0.002). Concomitant CABG was not an independent risk factor for adverse long-term survival (HR: 0.89; 95% CI: 0.77-1.02, p = 0.09). CONCLUSIONS The long-term survival of octogenarians who underwent AVR or AVR + CABG was similar and was not affected by adding concomitant CABG. However, octogenarians who underwent concomitant CABG with AVR had significantly higher in-hospital mortality. Each decision should be discussed within the heart team.
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Affiliation(s)
- Hannah Masraf
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Davorin Sef
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Sirr Ling Chin
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Gabriel Hunduma
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | | | - Szabolcs Miskolczi
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Theodore Velissaris
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Suvitesh Luthra
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
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Gallingani A, D’Alessandro S, Singh G, Hernandez-Vaquero D, Çelik M, Ceccato E, Nicolini F, Formica F. The impact of coronary artery bypass grafting added to aortic valve replacement on long-term outcomes in octogenarian patients: a reconstructed time-to-event meta-analysis. Interact Cardiovasc Thorac Surg 2022; 35:6611720. [PMID: 35723556 PMCID: PMC9272063 DOI: 10.1093/icvts/ivac164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
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The long-term results in studies comparing octogenarian patients who received either isolated surgical aortic valve replacement (i-SAVR) or coronary artery bypass grafting (CABG) in addition to SAVR are still debated. We performed a reconstructed time-to-event data meta-analysis of studies comparing i-SAVR and CABG+SAVR to evaluate the impact of CABG and to analyse the time-varying effects on long-term outcome. We performed a systematic review of the literature from January 2000 through November 2021, including studies comparing i-SAVR and CABG+SAVR, which reported at least 3-year follow-up and that plotted Kaplan–Meier curves of overall survival. The primary endpoint was overall long-term survival; secondary endpoints were in-hospital/30-day mortality and postoperative outcomes. The pooled hazard ratio (HR) and odds ratio) with 95% confidence interval (CI) were calculated for primary and secondary endpoints, respectively. Random-effect model was used in all analyses. Sixteen retrospective studies were included (5382 patients, i-SAVR = 2568 and CABG+SAVR = 2814). I-SAVR showed a lower incidence of in-hospital mortality compared to CABG+SAVR (odds ratio = 0.73; 95% CI= 0.60–0.89; P = 0.002). Landmark analyses showed a significantly higher all-cause mortality within 1 year from surgery in CABG+SAVR (HR = 1.17; 95% CI = 1.01–1.36; P = 0.03); after 1 year, no significant difference was observed (HR = 0.95; 95% CI = 0.87–1.04; P = 0.35). Landmark analysis was confirmed by time-varying trend of HR. Late survival of octogenarians did not differ significantly between the 2 interventions. Interestingly, CABG added to SAVR was associated with both higher in-hospital and within 1-year mortality after surgery, whereas this difference was statistically non-significant at long-term follow-up.
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Affiliation(s)
- Alan Gallingani
- Cardiac Surgery Unit, Parma University Hospital , Parma, Italy
| | | | - Gurmeet Singh
- Department of Critical Care Medicine and Division of Cardiac Surgery, Mazankowski, Alberta Heart Institute, University of Alberta , Edmonton, Canada
| | | | - Mevlüt Çelik
- Department of Cardiothoracic Surgery, Erasmus University Medical Center , Rotterdam, Netherlands
| | | | - Francesco Nicolini
- Medical Library, University of Parma , Parma, Italy
- Department of Medicine and Surgery, University of Parma , Parma, Italy
| | - Francesco Formica
- Medical Library, University of Parma , Parma, Italy
- Department of Medicine and Surgery, University of Parma , Parma, Italy
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D'Alessandro S, Tuttolomondo D, Singh G, Hernandez-Vaquero D, Pattuzzi C, Gallingani A, Maestri F, Nicolini F, Formica F. The early and long-term outcomes of coronary artery bypass grafting added to aortic valve replacement compared to isolated aortic valve replacement in elderly patients: a systematic review and meta-analysis. Heart Vessels 2022; 37:1647-1661. [PMID: 35532809 PMCID: PMC9399049 DOI: 10.1007/s00380-022-02073-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 03/31/2022] [Indexed: 11/27/2022]
Abstract
AbstractIn aged population, the early and long-term outcomes of coronary revascularization (CABG) added to surgical aortic valve replacement (SAVR) compared to isolated SAVR (i-SAVR) are conflicting. To address this limitation, a meta-analysis comparing the early and late outcomes of SAVR plus CABG with i-SAVR was performed. Electronic databases from January 2000 to November 2021 were screened. Studies reporting early-term and long-term comparison between the two treatments in patients over 75 years were analyzed. The primary endpoints were in-hospital/30-day mortality and overall long-term survival. The pooled odd ratio (OR) and hazard ratio (HR) with 95% confidence interval (CI) were calculated for in-early outcome and long-term survival, respectively. Random-effect model was used in all analyses. Forty-four retrospective observational studies reporting on 74,560 patients (i-SAVR = 36,062; SAVR + CABG = 38,498) were included for comparison. The pooled analysis revealed that i-SAVR was significantly associated with lower rate of early mortality compared to SAVR plus CABG (OR = 0.70, 95% CI 0.66–0.75; p < 0.0001) and with lower incidence of postoperative acute renal failure (OR = 0.65; 95% CI 0.50–0.91; p = 0.02), need for dialysis (OR = 0.65; 95% CI 0.50–0.86; p = 0.002) and prolonged mechanical ventilation (OR = 0.57; 95% CI 0.42–0.77; p < 0.0001). Twenty-two studies reported data of long-term follow-up. No differences were reported between the two groups in long-term survival (HR = 0.95; 95% CI 0.87–1.03; p = 0.23). CABG added to SAVR is associated with worse early outcomes in terms of early mortality, postoperative acute renal failure, and prolonged mechanical ventilation. Long-term survival was comparable between the two treatments.
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Affiliation(s)
| | | | - Gurmeet Singh
- Department of Critical Care Medicine and Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | | | - Claudia Pattuzzi
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Alan Gallingani
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | | | - Francesco Nicolini
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Formica
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy.
- Department of Medicine and Surgery, University of Parma, Parma, Italy.
- UOC Cardiochirurgia, Azienda Ospedaliera Universitaria di Parma, Via A. Gramsci, 14, 43126, Parma, Italy.
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5
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Komarov RN, Kleshchev PV. [Current problems of simultaneous surgery of the aortic valve and ischaemic heart disease]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:168-174. [PMID: 33332320 DOI: 10.33529/angio2020416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Surgical policy in treatment of patients suffering from concomitant valvular pathology and ischaemic heart disease is an extremely important problem of contemporary cardiac surgery. With the advent of advanced techniques and due to the improvement of old ones, there have over the last decades appeared new approaches to treatment of this cohort of patients. Presented in the article is a review of current publications regarding the problem of surgical treatment of patients with a combination of pronounced valvular pathology requiring surgical correction and ischaemic heart disease necessitating the need for myocardial revascularization. This is followed by providing the data concerning contemporary strategies of treatment of patients with concomitant pathology, as well as the comparison of various approaches and the effect of the chosen technique on the outcome.
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Affiliation(s)
- R N Komarov
- Department of Cardiovascular and Aortic Surgery, University Clinical Hospital #1, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - P V Kleshchev
- Cardiosurgical Department #42, Chief Military Clinical Hospital named after Academician N.N. Burdenko, Moscow, Russia
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Moss S, Doyle M, Hong R, Manganas C, Peeceeyen S. Octogenarians and aortic valve surgery: surgical outcomes in the geriatric population. Indian J Thorac Cardiovasc Surg 2020; 36:134-141. [PMID: 33061112 DOI: 10.1007/s12055-019-00853-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/09/2019] [Accepted: 07/16/2019] [Indexed: 12/29/2022] Open
Abstract
Background The era of percutaneous aortic valve intervention has challenged the continuing indication for surgical aortic valve replacement (SAVR). Aim The aim of this study is to evaluate clinical outcomes of the elderly patients who underwent surgical aortic valve replacement via median sternotomy, in order to assess the impact of surgery on patient outcomes and discharge destination. Methods The study involves a retrospective observational analysis in a single centre, including all octogenarian patients who underwent aortic valve surgery between January of 2011 and July of 2016. The study assessed pre-operative co-morbidities and post-operative outcomes, including long-term mortality and discharge destination following on from surgery. Results The mean age of patients was 82.7 years (± 2.9), 67% of whom were male. The mean EuroSCORE II was 8.1 (± 7.6). The most common pre-operative co-morbidities were dyslipidaemia (82%), hypertension (80%), and ischaemic heart disease (78.8%). The median length of stay was 10 days (± 6.9 days). Discharge home occurred in 71.8% of patients, with 21.2% of patients requiring transfer to a rehabilitation facility, and 1.2% of patients required placement into an aged care facility. There were five peri-operative deaths, equating to 5.9% of the cohort. Conclusion Despite high EuroSCORE II values for the majority of our patients, our data adds to overall suggestions that the octogenarian population can be considered eligible for SAVR and should not be excluded due to age alone. The use of the EuroSCORE II index more accurately predicts adequacy for treatment however does not entirely predict overall course of events, and proceduralist discretion should still be used.
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Affiliation(s)
- Stuart Moss
- St George Hospital, 1 Grey St, Kogarah, Sydney, New South Wales 2217 Australia
| | - Mathew Doyle
- St George Hospital, 1 Grey St, Kogarah, Sydney, New South Wales 2217 Australia
| | - Regina Hong
- St George Hospital, 1 Grey St, Kogarah, Sydney, New South Wales 2217 Australia
| | - Con Manganas
- St George Hospital, 1 Grey St, Kogarah, Sydney, New South Wales 2217 Australia
| | - Sheen Peeceeyen
- St George Hospital, 1 Grey St, Kogarah, Sydney, New South Wales 2217 Australia
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Takagi K, Arinaga K, Takaseya T, Otsuka H, Shojima T, Shintani Y, Zaima Y, Saku K, Oryoji A, Hiromatsu S. Aortic valve replacement with or without concomitant coronary artery bypass grafting in very elderly patients aged 85 years and older. Heart Vessels 2020; 35:1409-1418. [PMID: 32394242 DOI: 10.1007/s00380-020-01620-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/01/2020] [Indexed: 11/28/2022]
Abstract
Degenerative aortic stenosis is the most common structural heart valve disease affecting the aging population. Catheter-based heart valve interventions are less invasive and very useful for very elderly patients. However, we often consider open heart surgery for these patients because of anatomical reasons and co-existing cardiac diseases, i.e., severe coronary artery disease. We aimed to analyze the outcomes of very elderly patients aged ≥ 85 years undergoing aortic valve replacement (AVR) with or without coronary artery bypass grafting (CABG). Twenty-nine very elderly patients aged ≥ 85 years who underwent AVR with CABG (n = 11, Group AC) or isolated AVR (n = 18, Group A) were examined. The overall mean age of the patients was 87.2 ± 2.6 (range 85-94) years. The estimated operative mortality rate, calculated using the Japan score, EuroSCORE II, and STS risk score, was 5.72%-10.88% in Group AC and 5.63%-8.30% in Group A. Aortic cross-clamp time (126.5 ± 29.0 vs. 96.9 ± 29.2 min, p = 0.016) was significantly longer in Group AC than in Group A. Although the major morbidity rate was higher in Group AC than in Group A (36% vs. 6%, p = 0.0336), the length of intensive care unit stay and hospital stay was comparable between both groups. There was no 30-day and hospital mortality in both groups. Eleven patients died during follow-up (senility, 5; cerebrovascular events, 2; renal failure, 1; unknown, 3). There were no significant differences in survival rates during follow-up (log-rank p value = 0.1051). The 1-, 2-, 3-, 4- and 5-year survival rates were 91%, 80%, 69%, 69% and 69%, respectively, in Group AC and 94%, 94%, 94%, 94% and 88%, respectively, in Group A. In conclusion, AVR with or without CABG could be safely performed in carefully selected very elderly patients with acceptable early- and long-term results. AVR with CABG in very elderly patients aged ≥ 85 offers similar results to isolated AVR in terms of 30-day mortality, hospital mortality, and long-term survival.
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Affiliation(s)
- Kazuyoshi Takagi
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan.
| | - Koichi Arinaga
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Tohru Takaseya
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Hiroyuki Otsuka
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Takahiro Shojima
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Yusuke Shintani
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Yasuyuki Zaima
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Kosuke Saku
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Atsunobu Oryoji
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Shinichi Hiromatsu
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
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Del Forno B, Ascione G, Lapenna E, Trumello C, Ruggeri S, Belluschi I, Verzini A, Iaci G, Ferrara D, Schiavi D, Meneghin R, Castiglioni A, Alfieri O, De Bonis M. Is myocardial revascularization really necessary in patients with ≥50% but <70% coronary stenosis undergoing valvular surgery? Eur J Cardiothorac Surg 2020; 58:343-349. [DOI: 10.1093/ejcts/ezaa047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/22/2020] [Accepted: 01/25/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study is to evaluate the immediate and mid-term effects of omitting coronary artery bypass grafting in patients with moderate coronary artery stenosis who have a primary indication for valvular surgery.
METHODS
We included 77 consecutive patients admitted to our Institution for aortic or mitral valve surgery between June 2012 and June 2017 in whom a de novo diagnosis of ≥50%, but <70% coronary stenosis was made. In this cohort, the myocardial revascularization was omitted. All these patients were free from angina and ischaemia on echo and ECG.
RESULTS
There were no in-hospital deaths. In only 1 patient, acute myocardial infarction occurred postoperatively, which was immediately treated by percutaneous coronary intervention (PCI). The 6-year overall survival was 94.7 ± 2.59%. At 6 years, no cardiac deaths were recorded. At follow-up, 4 patients underwent elective PCI after a positive stress myocardial perfusion test. Only 1 patient underwent urgent PCI due to acute coronary syndrome. At 6 years, the cumulative incidence function of PCI, with death as competing risk, was 8 ± 3.9%.
CONCLUSIONS
In our experience, moderate coronary stenosis, occasionally discovered at the time of valvular heart surgery, can be safely overlooked and do not need any further treatment at follow-up in the majority of cases. Our results open up the opportunity to apply this ‘intentional omission strategy’ in different situations, such as minimally invasive heart surgery, percutaneous procedures and complex patients.
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Affiliation(s)
- Benedetto Del Forno
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Guido Ascione
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Elisabetta Lapenna
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Cinzia Trumello
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Stefania Ruggeri
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Igor Belluschi
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Verzini
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Iaci
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Davide Schiavi
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberta Meneghin
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Castiglioni
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Michele De Bonis
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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Does additional coronary artery bypass grafting to aortic valve replacement in elderly patients affect the early and long-term outcome? Heart Vessels 2019; 35:487-501. [PMID: 31642980 PMCID: PMC7222122 DOI: 10.1007/s00380-019-01519-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 10/02/2019] [Indexed: 11/18/2022]
Abstract
Early and long-term outcomes in elderly patients who underwent isolated aortic valve replacement (iAVR) are well defined. Conflicting data exist in elderly patients who underwent AVR plus coronary artery bypass grafting (CABG). We sought to evaluate the early and long-term outcomes of combined AVR + CABG in patients older than 75 years of age. From June 1999 to June 2018, 402 patients ≥ 75 years who underwent iAVR (n = 200; 49.7%) or combined AVR plus CABG (n = 202; 50.3%) were retrospectively analysed. AVR + CABG patients were older than iAVR patients (78.5 ± 2.5 vs 77.6 ± 2.8 years; p < 0.0001), with greater co-morbidities and more urgent/emergency surgery. 30-day mortality was 6.5% in the AVR + CABG and 4.5% in the iAVR group (p = 0.38). Multivariate analysis identified EuroSCORE II [odd ratio (OR) 1.13] postoperative stroke (OR 12.53), postoperative low cardiac output syndrome (OR 8.72) and postoperative mechanical ventilation > 48 h (OR 8.92) as independent predictors of 30-day mortality; preoperative cerebrovascular events (OR 3.43), creatinine (OR 7.27) and extracorporeal circulation time (OR 1.01) were independent predictors of in-hospital major adverse cardiovascular and cerebral events (MACCE). Treatment was not an independent predictor of 30-day mortality and in-hospital MACCE. Survival at 1, 5 and 10 years was 94.7 ± 1.6%, 72.6 ± 3.6% and 31.7 ± 4.8% for iAVR patients and 89.1 ± 2.3%, 73.9 ± 3.5% and 37.2 ± 4.8% for AVR + CABG subjects (p = 0.99). Using adjusted Cox regression model, creatinine [hazard ration (HR) 1.50; p = 0.018], COPD (HR 1.97; p = 0.003) and NYHA class (HR 1.39; p < 0.0001) were independent predictors of late mortality; the combined AVR + CABG was not associated with increased risk of late mortality (HR 0.83; p = 0.30). In patients aged ≥ 75 years, combined AVR + CABG was not associated with increased 30-day mortality, in-hospital MACCE and long-term mortality. Surgical revascularization can be safely undertaken at the time of AVR in elderly patients.
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10
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Zheng Y, Li T. Association between transcatheter aortic valve implantation or replacement and mortality, and major adverse events after coronary artery bypass grafting. IJC HEART & VASCULATURE 2018; 21:57-63. [PMID: 30310852 PMCID: PMC6178209 DOI: 10.1016/j.ijcha.2018.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 07/29/2018] [Accepted: 08/22/2018] [Indexed: 11/09/2022]
Abstract
Background In recent years, many people are opting for minimally invasive surgery in China. Patients undergoing transcatheter aortic valve implantation or replacement (TAVIR) with previous coronary artery bypass grafting (CABG) have higher risks of death and major complications. Materials/methods PubMed and Embase were searched for all comparison studies between TAVIR with and without prior CABG and mortality as a primary outcome, irrespective of surgical risk, to investigate whether patients with prior CABG can undergo TAVIR. Randomized controlled trials and propensity-score-matched cohort studies were eligible for inclusion. The outcomes of interest included 30-day, 6-month, and 1-year mortality and 30-day complications. If significant heterogeneity was found in the random-effects meta-analyses, a sensitivity analysis that individually removed each study was conducted. Results Five studies reported results on patients undergoing TAVIR with or without prior CABG. Compared with the non-CABG cohort, the CABG cohort showed no significant difference in the 30-day, 6-month, and 1-year mortality and the 30-day risk of major complications, except life-threatening bleeding. However, for the 30-day risk of life-threatening bleeding, the morbidity of CABG cohort was significantly lower than that of the non-CABG cohort (risk ratio 0.555; 95% confidence interval 0.35–0.85; P = 0.006; I2 = 0%). Conclusions Patients with prior CABG can undergo TAVIR. Patients undergoing TAVIR without prior CABG need more attention because of a higher risk of life-threatening bleeding.
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Affiliation(s)
- Yue Zheng
- The Third Central Clinical College of Tianjin Medical University, Tianjin 300170, China.,Tianjin Key Laboratory of Artificial Cell, China.,Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Tong Li
- The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin 300170, China.,Tianjin Key Laboratory of Artificial Cell, China.,Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
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Li H, Gu C. Off-Pump Semicircular Annuloplasty: Effective Treatment of Concurrent Moderate Aortic Regurgitation. Ann Thorac Surg 2017. [PMID: 28633279 DOI: 10.1016/j.athoracsur.2017.01.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The treatment of aortic regurgitation (AR) in patients undergoing off-pump coronary artery bypass grafting (CABG) is a difficult problem. Aortic valve repair has become a promising therapy for AR. Various annuloplasty approaches have been used and have gained satisfactory results. Thus we adopted off-pump semicircular annuloplasty to treat concurrent moderate AR in 12 high-risk patients. Early follow-up results showed that this way is simple, safe, and effective.
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Affiliation(s)
- Haiming Li
- Department of Cardiac Surgery, Beijing An Zhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Chengxiong Gu
- Department of Cardiac Surgery, Beijing An Zhen Hospital, Capital Medical University, Beijing, China.
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