When is concomitant aortic valve replacement indicated in patients with mild to moderate stenosis undergoing coronary revascularization?

Mild to moderate aortic stenosis is a common finding in patients presenting for coronary artery bypass grafting (CABG), and its management is controversial. However, review of available data suggests a surgical strategy for these patients. Recent data demonstrate that 1) progression of aortic stenosis is more rapid in those with leaflet calcification; 2) the addition of aortic valve replacement to CABG in patients with mild to moderate stenosis does not increase hospital mortality when compared with bypass surgery alone; 3) hospital mortality for aortic valve replacement after previous bypass surgery has declined in recent years; 4) aortic valve replacement places the patient at risk for prosthesisrelated complications; 5) the limited 10-year survival (competing risk of death) leaves only a minority of individuals with mild aortic stenosis alive and eligible for aortic valve replacement 10 years after bypass surgery; and 6) combined aortic valve replacement and CABG confers a survival benefit in those with moderate aortic stenosis but not in those with mild aortic stenosis. Therefore, in the coronary artery bypass patient with moderate aortic stenosis, leaflet calcification, and life expectancy greater than 5 years, concomitant aortic valve replacement is advised. In contrast, aortic valve replacement is rarely indicated in those with mild aortic stenosis.     

Aortic valve replacement for aortic stenosis in persons aged 80 years and over

Seventy-one patients aged greater than or equal to 80 years (mean +/- standard deviation 82 +/- 2) with aortic stenosis or mixed stenosis and regurgitation underwent aortic valve replacement alone (n = 35, group 1) or in combination with a coronary artery bypass procedure without any other valve procedure (n = 36, group 2). Preoperatively, 91% had severe cardiac limitations (New York Heart Association class III or IV). Hospital mortality was 12.7% overall (9 of 71), 5.7% (2 of 35) for group 1 and 19.4% (7 of 36) for group 2. Perioperatively, 1 patient (1.4%) had a stroke. Survival from late cardiac death at 1 and 3 years was 98.2 and 95.5%, respectively, for all patients, 100% for patients who underwent isolated aortic valve replacement, and 96.3 and 91.2%, respectively, for patients who underwent aortic valve replacement plus coronary artery bypass. Eighty-three percent of surviving patients had marked symptomatic improvement. Freedom from all valve-related complications (thromboembolism, anticoagulant, endocarditis, reoperation or prosthetic failure) was 93.3 and 80.4% at 1 and 3 years, respectively. Thus, short- and long-term morbidity and mortality after aortic valve replacement for aortic stenosis in patients aged greater than or equal to 80 years are encouragingly low, although the addition of coronary artery bypass grafting increases short- and long-term mortality.     

Should coronary artery bypass graft surgery patients with mild or moderate aortic stenosis undergo concomitant aortic valve replacement? A decision analysis approach to the surgical dilemma

OBJECTIVES: This study utilizes Markov decision analysis to assess the relative benefits of prophylactic aortic valve replacement (AVR) at the time of coronary artery bypass graft surgery (CABG). Multiple sensitivity analyses were also performed to determine the variables that most profoundly affect outcome. BACKGROUND: The decision to perform CABG or concomitant CABG and AVR (CABG/AVR) in asymptomatic patients who need CABG surgery but have mild to moderate aortic stenosis (AS) is not clear-cut. METHODS: We performed Markov decision analysis comparing long-term, quality-adjusted life outcomes of patients with mild to moderate AS undergoing CABG versus CABG/AVR. Age-specific morbidity and mortality risks with CABG, CABG/AVR, and AVR after a prior CABG were based on the Society of Thoracic Surgeons national database (n = 1,344,100). Probabilities of progression to symptomatic AS, valve-related morbidity, and age-adjusted mortality rates were obtained from available published reports. RESULTS: For average AS progression, the decision to replace the aortic valve at the time of elective CABG should be based on patient age and severity of AS measured by echocardiography. For patients under age 70 years, an AVR for mild AS is preferred if the peak valve gradient is >25 to 30 mm Hg. For older patients, the threshold increases by 1 to 2 mm Hg/year, so that an 85-year-old patient undergoing CABG should have AVR only if the gradient exceeds 50 mm Hg. The AS progression rate also influences outcomes. With slow progression (<3 mm Hg/year), CABG is favored for all patients with AS gradients <50 mm Hg; with rapid progression (>10 mm Hg/year), CABG/AVR is favored except for patients >80 years old with a valve gradient <25 mm Hg. CONCLUSIONS: This study provides a decision aid for treating patients with mild to moderate AS requiring CABG surgery. Predictors of AS progression in individual patients need to be better defined.     

Coronary lesions due to aortic valve disease. II -- Results and indications of aortocoronary bypass surgery]

454 cases of aortic valve replacement were studied: 217 had no significant coronary artery disease, 197 had associated aorto-coronary bypass surgery and 40 coronary artery disease without revascularization surgery:-- The early mortality in the three groups was 5.5%, 21% and 12.5% respectively, the only statistically significant difference being between the first two groups. -- The coronary artery disease was signigicantly more severe in the group which underwent associated aorto-coronary bypass surgery. The early mortality was significantly raised in the group without bypass surgery in cases with severe coronary artery disease (28%) and in the group with bypass surgery with unsuitable coronary artery lesions (35.5%). On the other hand, the long term survival and functional capacity of patients who underwent associated bypass surgery approached that of the non-coronary patients. Combined aortic valve replacement and coronary bypass surgery should therefore be continued in selected cases.     

Spontaneous course of aortic valve disease

The fate of patients with aortic valve disease of varying degrees of severity and the relationship between symptoms and haemodynamic status have been studied in 190 adults undergoing cardiac catheterization during the last two decades. During the follow-up period, 41 patients died and 86 underwent aortic valve replacement; these two events were the endpoints for the calculation of 'event-free' cumulative survival. First-year survival in haemodynamically severe disease was 60% in aortic stenosis and 96% in aortic regurgitation; in moderate and mild disease (in the absence of coronary artery disease) first-year survival was 100% in both groups. After 10 years, 9% of those with haemodynamically severe aortic stenosis and 17% of those with severe regurgitation were event-free, in contrast to 35% and 22%, respectively, of those with moderate changes and 85% and 75%, respectively, of those with mild abnormalities. In the presence of haemodynamically severe disease, 66% of the patients with stenosis and 14% of those with regurgitation were severely symptomatic (history of heart failure, syncope or New York Heart Association class III and IV); 23% of patients with moderate stenosis and 14% with moderate regurgitation were also severely symptomatic. Only 40% of those with disease that was severe both haemodynamically and symptomatically with either stenosis or regurgitation survived the first two years; only 12% in the stenosis group and none in the regurgitation group were event-free at 5 years. Patients with haemodynamically severe aortic stenosis who had few or no symptoms had a 100% survival at 2 years; the comparable figure for the aortic regurgitation group was 94%; 75% of the patients in the stenosis group and 65% in the regurgitation group were event-free at 5 years. In the moderate or mild stenosis and regurgitation groups there was no mortality within the first 2 years in the absence of coronary artery disease, regardless of symptomatic status. Haemodynamically and symptomatically severe aortic stenosis and regurgitation have a very poor prognosis and require immediate valve surgery. Asymptomatic and mildly symptomatic patients with haemodynamically severe aortic stenosis are at low risk and surgical treatment can be postponed until marked symptoms appear without a significant risk of sudden death. In severe aortic regurgitation, the decision for surgery should depend not only on symptoms but should be considered in patients with few or no symptoms because of risk of sudden death. In the absence of coronary artery disease, moderate aortic valve disease does not require valve operation for prognostic reasons.     

Timing of surgery in aortic stenosis

In adults with valvular stenosis, the importance of prompt aortic valve replacement once symptoms occur is well known. The operative mortality for aortic valve replacement has improved dramatically over the past 4 decades and remains the only effective therapy for severe symptomatic aortic stenosis. Aortic valve replacement in patients with left ventricular dysfunction has a high operative mortality, although those patients who do not undergo surgery at all have an even worse outcome. While issues to consider include the presence or absence of coronary artery disease and expected hemodynamics of the prosthetic valve compared with the native valve, when in doubt, one should err on the side of surgical intervention. Elderly age is not a contraindication to aortic valve replacement for severe symptomatic aortic stenosis, although there is a higher prevalence of comorbid disease and higher operative mortality. Life expectancy is significantly prolonged and quality of life is significantly improved in the elderly who survive surgery. Indications for surgery in asymptomatic patients are controversial. We do not recommend valve replacement in asymptomatic patients at this time due to the known risks of surgery and a prosthetic valve and the lack of evidence for benefit of early surgery. Patients undergoing coronary bypass surgery should be considered for concomitant aortic valve surgery for moderate aortic stenosis that is expected to progress to severe stenosis in less than 5 years. Copyright © 2001 by W.B. Saunders Company

Progress in Cardiovascular Diseases, Vol. 43, No. 6 (May/June) 2001: pp 477-493     

Should a Regurgitant Mitral Valve Be Replaced Simultaneously with a Stenotic Aortic Valve?

Mitral valve regurgitation frequently accompanies aortic valve stenosis. It has been suggested that mitral regurgitation improves after aortic valve replacement alone and that the mitral valve need not be replaced simultaneously Furthermore, mitral regurgitation associated with coronary artery disease, particularly in patients with poor left ventricular function, shows immediate improvement after coronary artery bypass grafting. We studied 60 consecutive patients with aortic stenosis and mitral regurgitation to determine the degree of improvement in mitral regurgitation after aortic valve replacement alone versus aortic valve replacement combined with coronary artery bypass grafting. Thirty-six of the patients had normal coronary arteries (Group 1); the other 24 had symptomatic coronary artery disease requiring bypass surgery (Group 2). Echocardiography was performed preoperatively, 1 week postoperatively, and at follow-up. In Group 1, left ventricular ejection fraction did not improve early or at 2.5 months postoperatively, but mitral regurgitation improved gradually during follow-up. In Group 2, mitral regurgitation showed improvement 1 week postoperatively (p < 0.001), and left ventricular ejection fraction was improved at 2.5 months. We conclude that patients with aortic valve stenosis and mild-to-severe mitral regurgitation, without echocardiographic signs of chordal or papillary muscle rupture and without coronary artery disease, should undergo aortic valve replacement alone. The mitral regurgitation will remain the same or improve. For patients with coexisting coronary artery disease, simultaneous aortic valve replacement and coronary artery bypass grafting are imperative; however, the mitral valve again requires no intervention, since mitral regurgitation improves significantly after the other 2 procedures.     

Management of asymptomatic aortic stenosis in patients undergoing coronary artery bypass grafting.

This study compared the outcomes of combined coronary artery bypass grafting (CABG)/aortic valve replacement (AVR) and CABG alone in patients with moderate aortic stenosis and determined the possible indications for AVR at the time of CABG. Between December 1988 and January 2001, in Tenri Hospital, 41 patients with aortic stenosis underwent CABG: 26 patients underwent the combined procedure and 15 patients underwent CABG alone. The patients who underwent CABG alone were separated them into 2 groups on the basis of the results of annual echocardiography: the rapid progression group, defined by an increase of deltaP by >/=10 mmHg/year, and the slow progression group. Of the 15 patients who underwent CABG alone, the probability of survival at the end of the study in 2001 was 92% at 5 years and 74% at 10 years, and the respective event-free rates were 65% and 50%. Patients less than 70 years old and who were in the rapid progression group had a greater risk for re-operation. The study suggests that patients younger than 70 years old with risk factors for rapid progression should undergo CABG/AVR, and conversely, those older than 70 years old without the risk factors can undergo CABG only.     

Hemodynamic progression of adult valvular aortic stenosis

Hemodynamic progression of valvular aortic stenosis was studied in 54 patients who had serial cardiac catheterizations. There were 47 men and 7 women with a mean age of 61.2 years. The time interval between studies was 4.4 years (range, 0.4-12.2). Associated coronary artery disease was present in 37 patients (69%). The initial mean aortic valve area (Hakki's formula) was 1.26 cm2 (range, 0.66-2.85), and the aortic valve area at last follow-up was 0.77 cm2 (range, 0.29-1.95), with mean reduction of 0.49 cm2. The mean peak systolic gradient increased from 23.3 +/- 15.1 mm Hg at initial study to 52.6 +/- 27.5 mm Hg at last study, a mean increase of 29.3 +/- 23.6 mm Hg. Patients with no or mild left ventricular impairment and no or mild coronary artery disease are more likely to have progression than patients with more severe left ventricular impairment or coronary artery disease (P less than 0.05). Aortic valve replacement for progressive aortic stenosis was required at a later date after coronary artery bypass grafting in a small group of nine patients. In this small group, there was high intraoperative mortality of 33%.     

Aortic valve replacement with the Sorin Pericarbon Freedom stentless valve: five-year follow up

BACKGROUND AND AIM OF THE STUDY: Presumed benefits from stentless bioprostheses include larger orifice areas with lower transvalvular gradients, and improved hemodynamic flow characteristics and annular mechanics. Herein are reported the results of a large series of the Sorin Pericarbon Freedom stentless valve implanted in the aortic position. METHODS: Between July 1998 and June 2003, a total of 102 consecutive patients (58 males, 44 females; mean age 71.7+/-7.8 years; range: 28-87 years) requiring aortic valve replacement (AVR), including those undergoing concomitant procedures of coronary artery bypass, mitral valve repair and mini-maze, was recruited. The predominant lesion was aortic stenosis (n = 92; 90.2%); aortic regurgitation (AR) occurred in five patients (4.9%) (including three with endocarditis), and mixed aortic valve disease in five (4.9%). Six patients (5.9%) had undergone previous cardiac surgery. The median preoperative NYHA class was III. Thirsty-six patients (35.3%) underwent AVR alone. The mean valve size was 25 mm (range: 21-29 mm). Sixty-three patients (61.8%) had concomitant coronary artery disease that required a mean of 2.4+/-1.1 bypass grafts; three patients (3.0%) had combined AVR and mitral valve repair. The study end points observed were mortality, valve failure due to degeneration or endocarditis, reoperation, thromboembolism, transvalvular gradients and left ventricular (LV) mass regression. RESULTS: The median follow up for all patients was 31 months (range: 12 months to 5 years). The mean total cross-clamp time was 71.7+/-17.6 min without associated procedures, and 93.9+/-19.7 min with concomitant procedures. Early mortality was 4/102 (3.8%); actuarial survival over five years was 89.2%. Freedom from thromboembolism over five years was 95.9%, from reoperation 100%, and from endocarditis 99.98%. Fifty-seven patients (56.4%) had no AR detected postoperatively, and 34 (33.3%) had trivial or mild AR. A significant decline was observed in indexed LV mass regression within six months of surgery, from 190+/-72 g/m(2) at baseline to 152+/-47 g/m(2) (p = 0.01). CONCLUSION: In an elderly population with a high incidence of coronary artery disease, the Sorin Pericarbon Freedom stentless valve offers excellent hemodynamics, resulting in significant regression of left ventricular hypertrophy, together with acceptable operation times, morbidity and mortality in the medium term.     

Management of patients undergoing coronary artery bypass graft surgery with mild to moderate aortic stenosis

BACKGROUND AND AIM OF THE STUDY: The management of patients undergoing coronary artery bypass graft (CABG) surgery with mild to moderate aortic stenosis (AS) remains controversial. The study aim was to examine the outcome in patients with mild to moderate AS undergoing CABG. METHODS: A retrospective analysis was carried out of 200 patients with coronary artery disease requiring CABG and with a peak AS gradient < 40 mmHg measured by Doppler echocardiography, between 1990 and 2000. Among patients, 154 underwent isolated CABG (group A) and 46 CABG + aortic valve replacement (AVR) (group B). RESULTS: Mortality was 2.6% (n = 4) in group A and 6.5% (n = 3) in group B (p = NS). The median AS gradients were 34 and 40 mmHg, respectively. Thirty patients (20%) in group A were in NYHA class III-IV compared to 20 (44%) in group B (p = 0.002). There was no significant difference in postoperative complications. The mean intensive care unit stay was 2.3 and 2.2 days, respectively (p = NS); median postoperative stay was 6 and 8 days, respectively (p = 0.02). During the median follow up period of 4.2 years no patient in group A required AVR. Nine late deaths occurred in group B, none of which was cardiac-related. CONCLUSION: Morbidity and mortality in patients who underwent combined surgery was comparable with that in patients who had isolated CABG. However, none of the patients who underwent only CABG required AVR during the follow up period. It is concluded that patients with mild AS at the time of CABG should not undergo AVR. It is possible that a cut-off AS gradient > 40 mmHg should be considered for combined surgery.     

The prognostic value of calcification and impaired valve motion in combined aortic stenosis and coronary artery disease

BACKGROUND AND AIMS OF THE STUDY: Optimal management of patients with coronary artery disease and concomitant aortic valve stenosis remains a subject of controversy. In this retrospective study, an attempt was made to identify criteria indicating rapid progression of aortic valve stenosis in patients with coronary artery disease. METHODS: Between 1990 and 1999, 47 patients underwent aortic valve replacement (AVR) after previous coronary artery bypass grafting (CABG) at the authors' institution. The postoperative data, including cardiac catheterization films, were reviewed. RESULTS: Aortic valve disease, mainly aortic stenosis, showed a rapid rate of progression. During a mean interval between CABG and AVR of 5.9 +/- 2.9 years, the mean peak-to-peak pressure gradient across the aortic valve rose from 16.1 +/- 13.8 to 61.4 +/- 23.9 mmHg in patients where presence of calcification and impaired aortic valve motion was found (66.0% of patients had calcified aortic valves; 72.3% had impaired valve motion) at the time of CABG; whereas in those without calcification and/or impaired leaflet motion a mean of 9.2 +/- 0.8 years elapsed before AVR became necessary. CONCLUSION: If a patient must undergo surgery for coronary artery disease, then AVR should be considered not only on the basis of hemodynamic criteria but also with regard to calcification of the aortic valve and its leaflet motion.     

Late results of combined mitral valve replacement and coronary bypass surgery

The incremental risk of coronary bypass surgery was analyzed in 718 patients undergoing mitral valve replacement between 1971 and 1983. Ninety-eight patients (14%) had significant coronary artery disease requiring coronary bypass surgery. In 70 of these patients, the origin of the mitral valve disease was nonischemic, whereas 28 patients had ischemic mitral regurgitation unsuitable for conservative valve surgery. There were six operative deaths (9%) and four perioperative myocardial infarctions (6%) after mitral valve replacement and coronary bypass surgery for nonischemic mitral valve disease. Operative mortality was related to low output cardiac failure before operation or perioperative myocardial infarction. Actuarial curves predict survival (+/- standard error) of 55 +/- 7% at 5 years and 43 +/- 8% at 10 years. Preoperative functional class was the only significant predictor of long-term survival in this group (p less than 0.05). The actuarial survival of the 620 patients without coronary artery disease who underwent mitral valve replacement alone was 63 +/- 3% at 10 years. This was significantly better than that of the 70 patients who underwent mitral valve replacement and coronary bypass surgery for nonischemic mitral valve disease (p less than 0.001). Conversely, 5 year survival of the 28 patients with ischemic mitral regurgitation was 43 +/- 10%. This confirms the negative detrimental effect of an ischemic origin of mitral valve disease on survival after mitral valve replacement and coronary bypass surgery (p less than 0.0001).     

Surgical management of a patient with combined heart pathologies and lung cancer. A simultaneous coronary artery bypass surgery,aortic valve replacement,tricuspid valve repair and pulmonary resection

Coexisting coronary artery disease and significant heart valve disease represent a considerable risk factor in patients undergoing pulmonary resection. The possibility to perform concomitant (simultaneous) heart and lung surgery could be a good option for many patients.In the presented case report, the intervention was performed on two valves, triple coronary artery bypass and pulmonary resection, which has not been published in literature to date.A 68-year-old woman with coronary artery disease, aortic valve stenosis, tricuspid valve regurgitation and pulmonary disease (malignant pathology) presented with triple vessel disease, moderate aortic valve stenosis, severe tricuspid regurgitation and tumorous infiltration in the upper lobe of the left lung. She underwent combined heart and pulmonary surgery-left upper lobectomy, aortic valve replacement, tricuspid valve repair and coronary artery bypass surgery. On the eight day of surgery, she was discharged. She continues to do well on follow-up.Simultaneous cardiac surgery and pulmonary resection for malignancy become almost standard treatment of patients who require heart and lung surgery. The most often approach is midline sternotomy that enables a comfortable cardiac intervention as well as an acceptable access to lungs. The left lower lobectomy remains an exception, in which pulmonary resection during extracorporeal circulation (ECC) is more often an option of left thoracotomy. If the use of ECC is inevitable, some authors prefer pulmonary resection before starting up ECC if the location of the neoplasm does not require resection during ECC.     

Total arterial revascularization and concomitant aortic valve replacement

The safety of total arterial revascularization with a left internal thoracic artery-radial artery T-graft was evaluated in patients with at least two-vessel coronary artery disease and aortic valve stenosis requiring concomitant aortic valve replacement. From June 2001 to January 2005, 18 patients underwent aortic valve replacement and total arterial revascularization, while 101 had aortic valve replacement and conventional grafting. By matching age, sex, left ventricular ejection fraction, and number of distal anastomoses, 1:2 matched groups were generated: 15 patients with a left internal thoracic-radial artery T-graft, and 30 with left internal thoracic artery and additional vein grafts. Aortic cross clamp and cardiopulmonary bypass times were similar in both groups. There were no significant differences in postoperative data between the groups. Early mortality was 0% in the T-graft group and 2% in those with conventional grafts. Follow-up ranged from 2 to 50 months. Event-free survival was 100% in the T-graft group and 90% in the conventional graft group. Total arterial grafting with a left internal thoracic-radial artery T-graft can be performed in selected patients with aortic valve stenosis requiring simultaneous aortic valve replacement.     

Coronary artery disease and its management: influence on survival in patients undergoing aortic valve replacement

Data from 1,156 patients greater than or equal to 30 years of age who underwent aortic valve replacement alone or with coronary artery bypass grafting from 1967 through 1976 (early series) and 227 similar patients operated on during 1982 and 1983 (late series) were reviewed. In the early series, 414 patients (36%) had preoperative coronary arteriography (group 1): group 1A (n = 224) did not have coronary artery disease, group 1B (n = 78) had coronary artery disease but did not undergo bypass grafting and group 1C (n = 112) had coronary artery disease and underwent bypass grafting. The 742 patients in group 2 did not have preoperative arteriography. Operative mortality rates (30 day) in groups 1A, 1B, 1C and 2 were 4.5, 10.3, 6.3 and 6.3%, respectively (p = NS). The 10 year survival in both groups 1 and 2 was 54%; in groups 1A, 1B and 1C it was 63, 36 and 49%, respectively (1A and 1B, p less than 0.01). In the late series, the 227 patients were divided into similar groups (group 1A, n = 73; 1B, n = 32; 1C, n = 99), and 90% had preoperative coronary arteriography. Operative mortality rates (30 day) for groups 1A, 1B and 1C were 1.4, 9.4 and 4.0%, respectively; that for group 2 (no preoperative arteriography, n = 23) was 4.3%. Definition of coronary anatomy by angiography seems important in most patients greater than or equal to 50 years old who are candidates for aortic valve replacement, and bypass grafting is recommended for those with significant coronary artery disease.     

Aortic valve replacement in elderly patients: what are the limits?

PURPOSE OF REVIEW: Increased life expectancy has led to a growing elderly population frequently presenting with aortic stenosis. This review focuses on modalities of aortic valve replacement designed to cope with the risks from multiple co-morbidities prevalent in the elderly. RECENT FINDINGS: Cardiac surgery is safe in octogenarians; very low risks are associated with aortic valve replacement. Good short-term and medium-term results are seen with early surgical intervention for aortic stenosis in the relatively asymptomatic patient. The benefits seen with minimally invasive surgery make it more acceptable. A hybrid approach that deploys a drug-eluting stent for concomitant moderate coronary artery disease has shown promising results. An extension of this concept is the percutaneous aortic valve implantation that offers hope to the nonsurgical candidate. A systematic approach of minimally invasive surgery in patients with prior coronary artery bypass grafting minimizes injury to grafts. Bioprosthetic tissue valves are the valves of choice in all the above interventions. SUMMARY: Cardiac surgery is used increasingly for aortic stenosis in elderly patients. Current experiences in minimally invasive and percutaneous approaches have opened the doors to hybrid strategies, which may be the mainstay of treatment for older patients needing aortic valve replacements in the future.     

Impact of coronary artery disease on valvular heart surgery

Patients who undergo coronary bypass grafting in association with aortic valve replacement currently have a low in-hospital mortality, but their late survival is inferior to that of patients without coronary disease who undergo isolated aortic valve replacement. Patients who receive porcine heterografts to replace the aortic valve have better late survival and event-free survival after aortic valve replacement combined with bypass grafting than those who received mechanical valves. The analyses of patients who combine coronary artery and mitral valve disease is difficult because of changing surgical practices and diagnostic techniques. Patients undergoing surgery for mitral valve replacement combined with bypass grafting have had higher in-hospital mortality and worse late survival than patients undergoing aortic valve replacement combined with bypass grafting. The increased use of techniques for reconstructing rather than replacing the mitral valve may help improve the long-term results for patients undergoing surgery for mitral valve dysfunction combined with coronary disease.     

Effect of coronary bypass and valve structure on outcome in isolated valve replacement for aortic stenosis

Reports differ regarding the effect of concomitant coronary artery bypass grafting (CABG) in patients who undergo aortic valve replacement (AVR) for aortic stenosis (AS), and no reports have described the effect of aortic valve structure in patients who undergo AVR for AS. A total of 871 patients aged 24 to 94 years (mean 70) whose AVR for AS was their first cardiac operation, with or without first concomitant CABG, were included. Patients who underwent mitral valve procedures were excluded. In comparison with the 443 patients (51%) who did not undergo CABG, the 428 (49%) who underwent concomitant CABG were significantly older, were more often male, had lower transvalvular peak systolic pressure gradients and larger valve areas, had lower frequencies of congenitally malformed aortic valves, had lighter valves by weight, had higher frequencies of systemic hypertension, and had longer stays in the hospital after AVR. Early and late (to 10 years) mortality were similar by propensity-adjusted analysis in patients who did and did not undergo concomitant CABG. Congenitally unicuspid or bicuspid valves occurred in approximately 90% of those aged 21 to 50, in nearly 70% in those aged 51 to 70 years, and in just over 30% in those aged 71 to 95 years. Unadjusted and adjusted survival was significantly higher in patients with unicuspid or bicuspid valves compared to those with tricuspid valves. In conclusion, although concomitant CABG had no effect on the adjusted probability of survival, the type of aortic valve (unicuspid or bicuspid vs tricuspid) significantly affected the unadjusted and adjusted probability of survival.     

Outcome after valve replacement for severe aortic stenosis associated with reduced left ventricular ejection fraction

BACKGROUND AND AIM OF THE STUDY: Because valve replacement for aortic stenosis (AS) remains a difficult surgical challenge in the presence of left ventricular dysfunction, the immediate and long-term outcomes, and evolution of left ventricular ejection fraction (LVEF) in this setting, were analyzed. METHODS: Forty-three consecutive patients with severe AS (valve area < or =1 cm2) and reduced LVEF (< or =40%) who underwent valve replacement surgery at the authors' institution between April 1998 and December 2003 and were studied retrospectively. RESULTS: Preoperative characteristics included: LVEF 33 +/- 6%, mean transaortic pressure gradient 46 +/- 13 mmHg, and aortic valve area 0.58 +/- 0.15 cm2. Concomitant coronary artery bypass grafting was performed in 15 patients (35%). Perioperative (30-day) mortality was 2.3%, with 39.5% morbidity. During a mean follow up of 33.4 +/- 17.6 months, eight patients died. The Kaplan-Meier estimate of five-year survival was 75.3%. Postoperatively, none of the survivors remained in NYHA functional classes III-IV. The postoperative LVEF assessed in 81.8% of survivors had improved. Multivariate analysis associated improved LVEF with a higher preoperative mean transaortic pressure gradient (p = 0.0009) and a higher preoperative LVEF (p = 0.02). CONCLUSION: Patients with severe AS and reduced LVEF can undergo valve replacement with low perioperative mortality and moderate postoperative morbidity. Good long-term survival with good NYHA functional status and improved LVEF can be obtained.