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

In 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.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Aortic valve replacement with or without concomitant coronary artery bypass grafting in very elderly patients aged 85 years and older

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.

Does additional coronary artery bypass grafting to aortic valve replacement in elderly patients affect the early and long-term outcome?

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.

Outcomes after aortic valve replacement for aortic valve stenosis, with or without concomitant coronary artery bypass grafting

OBJECTIVES

To assess the effects of concomitant coronary artery bypass grafting (CABG), we analyzed the outcomes after aortic valve replacement (AVR) for aortic stenosis (AS) with and without coronary artery bypass grafting (CABG) at our institution.

METHODS

Between 2002 and 2014, 605 consecutive patients underwent AVR for AS. Of these, the 275 who received isolated AVR (Group A) and the 122 who received both AVR and CABG (Group AC) patients were enrolled, after the exclusion of 8 patients who underwent reoperation and 200 who received other concomitant surgery. AVR and all bypass anastomoses were performed under intermittent retrograde cold blood cardioplegia. Multivariate analysis was used to assess any association of concomitant CABG with morbidity and mortality. Kaplan-Meier analysis was used to assess all-cause mortality.

RESULTS

No significant difference in 30-day mortality was found between Group A and Group AC (1.5% vs. 0.8%, P = 1.000). Nor did post-discharge survival differ significantly between the two groups (P = 0.20). Likewise, multivariate analysis showed that concomitant CABG was not associated with significantly greater in-hospital or mid-term mortality. Operative morbidities were comparable between the two groups, in terms of stroke (1.8% vs. 3.3%, P = 0.466), prolonged ventilation (4.0% vs. 5.5%, P = 0.565), deep sternal infection (1.8% vs. 3.3%, P = 0.466), and acute renal failure (0.4% vs. 1.6% P = 0.176).

CONCLUSIONS

Concomitant CABG at the time of AVR was performed without increasing early- or mid-term mortality. This absence of increased risk deserves consideration when choosing between different treatment strategies.

Age as a Prognostic Factor in Patients with Acute Coronary Syndrome undergoing Urgent/Emergency Cardiac Surgery

BACKGROUND

Patients presenting with acute coronary syndrome (ACS) who require urgent/emergency coronary artery bypass grafting (CABG) are increasing, as is the complexity of their clinical characteristics, one of which is advanced age. We evaluated the prognostic role of age in patients undergoing urgent/emergency cardiac surgery for ACS.

METHODS

From January to December 2013, 452 consecutive patients underwent CABG at our institution. Among these, 213 presented with ACS, were enrolled in the study and divided into tertiles of age: First: 40-65 years old (n=73), Second: 66-74 (n=70), Third: 75-89 (n=70). Patients were followed post-operatively for 30 days.

RESULTS

No differences between tertiles were found for baseline clinical and angiographic characteristics. Off-pump interventions were 67.6%. Older patients more frequently required an associate intervention to CABG for a mechanical complication of ACS. Overall 30-day all-cause mortality was 4.7% (n=10); 0.6% (n=1) in patients undergoing isolated CABG (n=168, 78.9%). The STEMI diagnosis was an independent risk factor for 30-day mortality, and age was not.

CONCLUSIONS

The 30-day mortality rate of older ACS patients who undergo urgent/emergency CABG is comparable to that of younger ones. Pre-operative risk assessment should rely on evaluation of the clinical complexity of each patient independent of their chronological age, to customise the therapeutic strategy.

The prognostic impact of concomitant coronary artery bypass grafting during aortic valve surgery: implications for revascularization in the transcatheter era

OBJECTIVE

Clinicians may give greater consideration to medical management versus coronary artery bypass grafting (CABG) for coronary artery disease (CAD) at the time of aortic valve intervention. We evaluated the prognostic impact of revascularization strategy during aortic valve replacement (AVR).

METHODS

We studied 1308 consecutive patients with significant CAD (≥50% stenosis) undergoing AVR with or with out CABG between 2001 and 2010. Late mortality and its determinants were analyzed using multivariable Cox models.

RESULTS

Patients undergoing CABG (n = 1043; 18%) had more frequent angina (50% vs 26%; P < .001), left ventricular dysfunction (22% vs 14%; P = .003), advanced (>70% stenosis) CAD (85% vs 48%; P < .001), and incidence of triple-vessel/left-main CAD (44% vs 8%; P < .001). Whereas operative mortality was comparable between patients undergoing AVR plus CABG versus isolated AVR (2.9% vs 3.0%; P = .90), 5-year (72% vs 64%) and 8-year (50% vs 39%) survival was higher following CABG (P = .007). Adjusting for older age (hazard ratio [HR], 1.28 per 5 years), female sex (HR, 1.23), peripheral vascular disease (HR, 1.71), New York Heart Association functional class III to IV (HR, 1.48), and diabetes (HR, 1.50) concomitant CABG at AVR reduced late mortality risk by more than one-third (HR, 0.62, 95% confidence interval, 0.49-0.79; P < .001). CABG continued to confer a survival advantage in patients with moderate (50%-70%) (HR, 0.62; P = .02) and severe (>70%) CAD (HR, 0.62; P = .002).

CONCLUSIONS

In patients undergoing AVR with coexistent CAD, concomitant CABG reduces risk of late death by more than one-third, without augmenting operative mortality. This survival advantage persists in moderate (50% to 70%) and severe (>70%) CAD. These findings underline the prognostic importance of revascularization in this population and should influence decisions regarding revascularization strategy in patients undergoing transcatheter valve therapy.

Geriatric cardiac surgery: chronology vs. biology

Cardiac surgery is increasingly performed in elderly patients, and whilst the incidence of common risk factors associated with poorer outcome increases with age, recent studies suggest that outcomes in this population may be better than is widely appreciated. As such, in this review we have examined the current evidence for common cardiac surgical procedures in patients aged over 70 years. Coronary artery bypass grafting (CABG) in the elderly has similar early safety to percutaneous intervention, though repeat revascularisation is lower. Totally avoiding instrumentation of the ascending aorta with off-pump techniques may also reduce the incidence of neurological injury. Aortic valve replacement (AVR) significantly improves quality of life and provides excellent short- and long-term outcomes. Combined AVR and CABG carries higher risk but late survival is still excellent. Mini-sternotomy AVR in the elderly can provide comparable survival to full-sternotomy AVR. More accurate risk stratification systems are needed to appropriately select patients for transcatheter aortic valve implantation. Mitral valve repair is superior to replacement in the elderly, although choosing the most effective method is important for achieving maximal quality of life. Minimally-invasive mitral valve surgery in the elderly has similar postoperative outcomes to sternotomy-based surgery, but reduces hospital length of stay and return to activity. In operative candidates, surgical repair is superior to percutaneous repair. Current evidence indicates that advanced age alone is not a predictor of mortality or morbidity in cardiac surgery. Thus surgery should not be overlooked or denied to the elderly solely on the basis of their "chronological age", without considering the patient's true "biological age".