Aortic stenosis, angina pectoris, and coronary artery disease.

The relationships between aortic stenosis, coronary artery disease, angina pectoris, and myocardial infarction were examined in 173 patients with isolated calcific aortic stenosis who had coronary arteriography as well as cardiac catheterization. All were over age 40 and had definite cardiac symptoms; 156 later had aortic valve replacement. Coronary lesions narrowing the lumen by 50% or more were present in 37% of patients aged 40 to 59 and 68% of those aged 60 to 82. Coronary disease was present in 64% of patients with angina pectoris and 33% of those without angina. Angina which occurred only in association with dyspnea on exertion was associated with coronary disease in 45% of instances, whereas angina which also occurred on exertion without any dyspnea or which occurred with emotional stress, after meals, during sleep, or at rest unprovoked was associated with coronary disease in 80% of instances. Patients with coronary disease without any chest pain or with atypical pain considered nonanginal were men, usually over age 60, with congestive heart failure as the predominant symptom. Electrocardiograms showing transmural inferior or anterolateral infarction nearly always indicated coronary disease, while QS patterns in Leads V1-2 occurred frequently with normal coronary arteries. Serum cholesterol was elevated in 23% of those with coronary disease and 8% of those without. A group of patients with moderate aortic stenosis could be identified, with aortic valve areas of 0.55 to 0.80 cm. per square meter, in whom coronary disease was the sole or chief cause of symptoms. The operative mortality rate with aortic valve replacement was 9.6% in those with coronary disease and 1.4% in those without significant coronary disease. Coronary disease is frequently present in patients with calcific aortic stenosis, particularly in those over 60, those with angina, and those with symptoms despite only moderate aortic stenosis. The type of anginal syndrome, the ECG evidence of transmural infarction, and the coronary risk factors provide additional clues for clinical diagnosis.     

Angina pectoris and coronary artery disease in patients with severe aortic valvular disease

We studied the clinical, hemodynamic, and angiographic findings of 90 consecutive patients with significant symptomatic aortic valve disease, 40 years of age or older, to evaluate the prevalence of angina pectoris in relation to coronary artery disease and the effect upon cardiac function.The prevalence of chest pain was 66% (typical angina, 39%; atypical chest pain, 27%), and the prevalence of coronary artery disease was 39%. The prevalence of coronary artery disease in patients with typical angina was 77%, in contrast to 25% in patients with atypical chest pain $\text{(}\text{P}\text{= 0.001)}$. Only two of the 35 patients (6%) with coronary artery disease were free of chest pain. Although the incidence of coronary artery disease in patients with aortic stenosis was slightly higher than in patients with aortic regurgitation or aortic stenosis-aortic regurgitation, it was not statistically significant.Patients with aortic regurgitation and coronary artery disease had significantly lower ejection fraction than patients with aortic stenosis and coronary artery disease. There were no significant differences between ejection fraction in patients without coronary artery disease in the different groups. Patients with aortic stenosis and coronary artery disease tend to have lower mean pressure gradients than those without coronary artery disease. Patients with coronary artery disease in aortic regurgitation and aortic stenosis-aortic regurgitation tend to have higher left ventricular end-diastolic pressure.This study indicates that although patients with aortic valve disease and typical angina are most likely to have associated coronary artery disease, it is not possible to predict this disorder with accuracy by means of clinical or hemodynamic findings.Since the presence or absence of coronary artery disease in patients undergoing aortic valve replacement has prognostic and therapeutic significance, we recommend that coronary arteriography be performed in all patients with significant aortic valve disease undergoing cardiac catheterization when they present with any form of chest pain, or in patients over the age of 40 years even if no chest pain is present. Coronary arteriography would also rule out anomalous aortic origin of the coronary arteries.     

Chest pain as a predictor of coronary artery disease in patients with obstructive aortic valve disease

To clarify the association between chest pain and significant coronary artery disease in patients who have aortic valve disease, 76 consecutive candidates for aortic valve replacement were evaluated prospectively with use of a historical questionnaire and coronary arteriography. Of the 76 patients, 19 (25 percent) had no chest pain, 21 (28 percent) had chest pain that was not-typical of angina pectoris and 36 (47 percent) had chest pain typical of angina pectoris. In 18 of 19 patients the absence of chest pain correlated with the absence of coronary artery disease. The single patient without chest pain who had coronary artery disease had evidence of an inferior myocardial infarction in the electrocardiogram. Thus, absence of chest pain and the absence of electrocardiographic evidence of infarction predicted the absence of coronary disease in all cases.

The presence of chest pain did not predict the presence of coronary artery disease, but the more typical the pain of angina pectoris the more likely were patients to have significant coronary artery disease. Of the 21 patients with atypical chest pain, 6 (29 percent) had coronary artery disease, but of the 36 patients with typical angina pectoris 23 (64 percent) had significant coronary artery disease. In addition, when patients with chest pain not typical of angina pectoris also had coronary artery disease, the diseased vessels usually supplied smaller areas of the left ventricle than when the pain was typical of angina pectoris. In 21 of 23 patients (91 percent) with typical angina pectoris and significant coronary artery disease, lesions were present in the left coronary artery. There was no systolic pressure gradient across the aortic valve that excluded the presence of coronary artery disease, although all patients with a calculated aortic valve area of less than 0.4 cm² were free of coronary artery disease. Patients with severe left ventricular dysfunction were more likely to have normal coronary arteries.     

Clinical, haemodynamic, and coronary angiographic correlates of angina pectoris in patients with severe aortic valve disease.

Of 88 consecutive patients aged 20 to 77 years with severe symptomatic aortic valve disease requiring surgery, 51 patients had angina pectoris; of these 51, 41 had predominant aortic stenosis and 10 had severe aortic regurgitation. All patients with angina pectoris underwent coronary angiography; significant coronary arterial disease was encounted in 24 per cent of those with aortic stenosis and 20 per cent of those with aortic regurgitation. By contrast, of 37 patients without angina pectoris 19 underwent coronary arteriography; none showed significant coronary artery disease (P smaller than 0.05). Among patients with angina pectoris, 17 per cent of those with aortic stenosis experienced prolonged, rest or nocturnal pain, compared to 70 per cent of those with aortic regurgitation (P smaller than 0.005). At the time of onset of angina pectoris, there were features of heart failure in 34 per cent of those with aortic stenosis, and in 90 per cent of those with aortic regurgitation (P smaller than 0.005). Nitroglycerin promptly relieved angina pectoris in 56 percent of patients with aortic stenosis and in 50 per cent of those with aortic regurgitation (P smaller than 0.05). Neither the pattern of angina pectoris nor the response to nitroglycerin was dependent upon the coexistence of significant coronary artery disease. In patients with aortic stenosis, there was not significant difference between those with angina pectoris, and those without angina with regard to left ventricular end-diastolic volume, end-diastolic pressure, ejection fraction, peak systolic pressure, wall thickness, cardiac index, or the product of these factors. In patients with aortic regurgitation, cardiac index was significantly lower (P smaller than 0.05), left ventricular end-diastolic volume tended to be larger, and ejection fraction tended to be lower in patients with angina pectoris as opposed to those without angina pectoris.     

Electrocardiographic and serum enzyme changes of myocardial infarction after coronary artery bypass surgery

Serial preoperative and postoperative electrocardiograms were obtained in 50 patients undergoing coronary artery bypass surgery, 15 undergoing aortic valve replacement and 13 undergoing mitral valve surgery. Postoperative infarction was defined as the appearance of new Q waves on the postoperative electrocardiogram. Infarction occurred in 5 of 50 patients (10 percent) who underwent coronary artery bypass surgery. Age, preoperative hypertension or a pattern of left ventricular hypertrophy on the electrocardiogram did not correlate with infarction. Coronary disease was more severe in patients with than in those without infarction (mean of 3.2 vessels with 50 percent stenosis compared to 2.4 vessels). There was no correlation with bypass time or use of cross-clamping of the aorta during surgery. Postoperatively, 4 of 5 patients (80 percent) with infarction had serum values for glutamic oxaloacetic transaminase (SGOT) and creatine phosphokinase (CPK) of more than 200 and more than 2,000 international units, respectively, whereas 3 of 45 (7 percent) without infarction had this pattern (P < 0.001).Of patients undergoing aortic valve replacement, 3 of 15 (20 percent) had postoperative infarction. All 3 of these patients had a serum glutamic oxaloacetic transaminase value of more than 200 and a creatine phosphokinase value of more than 2,000 units, compared to 2 of 12 (17 percent) without infarction. None of the 12 patients who underwent mitral valve surgery had postoperative infarction, and none had a serum glutamic oxaloacetic transaminase value of more than 200 or a creatine phosphokinase value of more than 2,000 units.Myocardial infarction after coronary artery bypass surgery is more likely in patients with at least three-vessel disease but appears to be unrelated to pump time or aortic cross-clamping. Localized snaring or clamping of coronary arteries may be important. Postoperative serum glutamic oxaloacetic transaminase and creatine phosphokinase levels correlate with electrocardiographic evidence of infarction.     

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.     

Combined aortic valve replacement and myocardial revascularization: results in 220 patients.

During a 7.5-year period ending in June 1977, 220 patients underwent combined aortic valve replacement and myocardial revascularization. Early (30-day) mortality was 5.4% (12 patients), and was significantly affected by the development of perioperative myocardial infarction. For 23 patients with electrocardiographic and enzymatic evidence for definite infarction, hospital mortality was 17%; for 66 patients with probable infarction mortality was 5%; and for 116 patients without evidence for infarction mortality was 3%. The difference in mortality between the definite and no infarction groups was significant (p less than 0.01). The incidence of perioperative infarction was influenced by the type of myocardial protection employed during the operative procedure. Definite infarction occurred in 24% of 41 patients who had mild (28-32 degrees C), intermittent hypothermic coronary perfusion, in 9% of 142 patients with hypothermic ischemic arrest (myocardial temperature 20 to 27 degrees C) and in none of 22 patients with hypothermic, potassium-induced cardioplegia (myocardial temperature 8--18 degrees C). The difference in the rate of infarction between the coronary perfusion and the two hypothermic ischemic arrest groups was significant (p less than 0.01). The mean duration of followup for 100% of the hospital survivors was 22.5 months. Cumulative survival was 88% at 1 year and 77% at 3 years. These figures do not differ significantly from those for patients without coronary artery disease having isolated aortic valve replacement in our institution, and are superior to those reported for patients with coronary and aortic valve disease undergoing only aortic valve replacement. We conclude that combined aortic valve replacement and myocardial revascularization should be performed in all patients in whom the lesions coexist. Hypothermic ischemic arrest, preferably in combination with potassium-induced cardioplegia, provides the most myocardial protection during operation.     

Coronary anatomy and arteriography in patients with unstable angina pectoris.

A prospective series of 188 patients with the syndrome of unstable angina pectoris undergoing coronary arteriography was reviewed to determine the spectrum of anatomic coronary artery disease, suitability for coronary revascularization and in-hospital morbidity and mortality. Thirty-two patients demonstrated normal to moderately diseased coronary arteries. None of these patients sustained myocardial infarction or died. Twenty patients (10.6 percent) had normal coronary arteriograms. Of the 156 patients having severe coronary artery disease (greater than 70 percent stenosis), 20 patients (13 percent) had left main coronary artery disease. One hundred forty-two patients (91 percent) were potential candidates for coronary surgery; 14 were not candidates because of distal vessel disease or poor left ventricular function. During cardiac angiography or in the subsequent hospital period 12 patients sustained a myocardial infarction and 7 of these died. Of these seven, six had left main coronary artery disease and one had three vessel disease. In three patients who died (1.9 percent of those with severe coronary artery disease) the death may have been related to cardiac catheterization because evidence of myocardial necrosis began within 24 hours of study. Thus, patients with the syndrome of unstable angina pectoris usually presented with severe coronary artery disease and were candidates for coronary revascularization. The anatomic severity of coronary artery disease appeared to be the most important factor contributing to myocardlal infarction or death after cardiac catheterization. Mortality after catheterization was primarily associated with left main coronary artery disease.     

Long-term results of myocardial revascularization

During 1970 to 1977, among 1,733 patients who underwent isolated coronary bypass grafting, the operative mortality was 2.5 percent. Actuarial 5 year survival is 88.1 percent. At an average follow-up of 46 months (range 13 to 108), 90 percent of patients remain angina-free or with symptomatic improvement. The 5 year survival rate of patients with single vessel coronary artery disease is 97.9 percent. In patients with multivessel disease, operative survival appears to be favorably influenced by the presence of normal preoperative ventricular function. Late survival is significantly better in patients with multivessel disease with normal preoperative ventricular function or with complete revascularization. Risk of perioperative myocardial infarction has been appreciably reduced by the introduction of cold potassium chloride cardioplegia. Late myocardial infarction has occurred at an average annual risk of 1.46 percent. These data show that long-term survival and a small incidence of late myocardial infarction after myocardial revascularization are more likely in patients who undergo complete revascularization before significant left ventricular myocardial damage has occurred.     

Technical considerations in patients undergoing combined aortic valve replacement and aortocoronary bypass surgery.

Forty-nine patients have undergone combined aortic valve replacement and aortocoronary saphenous vein bypass graft surgery using a technique of distal coronary perfusion. Vein grafts are placed before replacement of the aortic valve, and continuously perfused by siting the proximal anastomoses high on the aortic root or individually perfusing the grafts before proximal anastomosis. Continuous coronary ostial perfusion is used as well during aortic valve replacement. There were 3 (6.1%) operative deaths and 1 (2%) perioperative myocardial infarction. A comparison of this technique with other reported results suggests that attention to myocardial perfusion distal to significant coronary artery stenosis may decrease the incidence of perioperative myocardial infarction in patients requiring both aortic valve replacement and coronary bypass graft operation.     

Technical considerations in patients undergoing combined aortic valve replacement and aortocoronary bypass surgery.

Forty-nine patients have undergone combined aortic valve replacement and aortocoronary saphenous vein bypass graft surgery using a technique of distal coronary perfusion. Vein grafts are placed before replacement of the aortic valve, and continuously perfused by siting the proximal anastomoses high on the aortic root or individually perfusing the grafts before proximal anastomosis. Continuous coronary ostial perfusion is used as well during aortic valve replacement. There were 3 (6.1%) operative deaths and 1 (2%) perioperative myocardial infarction. A comparison of this technique with other reported results suggests that attention to myocardial perfusion distal to significant coronary artery stenosis may decrease the incidence of perioperative myocardial infarction in patients requiring both aortic valve replacement and coronary bypass graft operation.     

Ad-hoc percutaneous coronary intervention and transcatheter aortic valve implantation as a combined transfemoral procedure

Coronary artery disease has been reported in more than 50% of patients with severe aortic stenosis above the age of 70 years. Combined surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) is associated with a higher operative risk. Concomitant coronary artery disease also increases the procedural risk of transcatheter aortic valve implantation (TAVI), and hence, a combined strategy for treating both entities needs to be carefully considered. Data regarding TAVI and percutaneous coronary intervention (PCI) as a combined percutaneous procedure are scarce. We report the case of an 84-year-old woman who presented with non-ST segment elevation myocardial infarction and impending pulmonary edema who was diagnosed with severe aortic stenosis and two-vessel coronary artery disease. Because of an elevated logistic Euroscore of 25% and her unstable presentation, percutaneous coronary revascularization and TAVI were successfully performed in a combined percutaneous transfemoral procedure. She had a smooth recovery and rehabilitation period with significant improvement in her symptoms and functional capacity. Thirty-day follow-up, including transthoracic echocardiography and cardiac magnetic resonance imaging, showed a well-functioning prosthetic valve and no signs of residual myocardial ischemia. We therefore conclude that combined PCI and TAVI is feasible and can be associated with good clinical outcomes in selected cases. Further data and experience are needed to evaluate this strategy.     

Atypical cause of hibernating myocardium due to complex cardiovascular lesions associated with Takayasu's arteritis

Myocardial hibernation is recognised as chronic hypoperfusion of the myocardium and its functional recovery after surgical revascularisation has been described. A case of surgery for complex lesions including severe aortic valve regurgitation, coronary ostial stenosis, and aortic calcification (porcelain aorta) caused by Takayasu's arteritis is presented. The onset of left ventricular functional improvement after aortic valve replacement and coronary revascularisation were indicative of preoperative atypical myocardial hibernation caused by aortic valve disease and coronary artery disease associated with Takayasu's arteritis.     

Results of coronary bypass and valve operations for mitral valve regurgitation

Combined coronary bypass grafting and valve procedures for mitral valve regurgitation result in poor outcomes, but the impact of the etiology of valve regurgitation on operative and long-term outcomes is not well defined. A retrospective analysis of 468 patients who had combined coronary bypass grafting and valve operations for mitral regurgitation showed that 78% had valve repairs and 22% had replacements for ischemic (45%) or degenerative (55%) disease. Predictors of operative mortality were ischemic mitral regurgitation, failure to use the internal mammary artery for grafting, severe coronary disease, acute myocardial infarction, low ejection fraction, advanced heart failure, emergency operation, and mitral valve replacement. The 5-year survival rates for propensity-matched patients with ischemic or degenerative disease were similar (66%). Low ejection fraction (< 35%), advanced age (> 67 years), valve replacement surgery, residual mitral regurgitation, and severe coronary artery disease were predictors of poor long-term outcome. Although the operative outcomes of ischemic mitral regurgitation were poor compared to those of degenerative disease, the long-term survival was similar in both groups of propensity-matched patients. Left ventricular remodeling, an optimal valve procedure without residual mitral regurgitation, and left ventricular function are more important determinants of long-term outcome than the etiology of valve regurgitation.     

Aortic valve regurgitation in alkaptonuria

Aortic valve lesions associated with alkaptonuria tend mostly to be due to aortic valve stenosis, while aortic valve regurgitation is only rarely observed. Herein, a case is reported of severe aortic valve regurgitation and a fibrous strand in a patient with alkaptonuria. A 65-year-old male, with a history of inferior myocardial infarction, presented with symptoms of congestive heart failure. Alkaptonuria was diagnosed based on urine coloration, skin pigmentation and ochronotic arthropathy in the vertebrae and hip. Grade IV aortic valve regurgitation with mild aortic valve stenosis and occlusive disease in the right coronary artery indicated a need for aortic valve replacement and coronary artery bypass grafting. Sclerotic change in the cusps, and shrinkage of the non-coronary cusp, impeded normal coaptation of the aortic valve, and the left-coronary cusp also had a fibrous strand suspending the free margin of the cusp from the aortic wall just above the commissure. The sclerotic change in the cusps, and shrinkage of the non-coronary cusp, appeared to be the causative lesion of aortic valve regurgitation, implying that cardiovascular ochronosis may cause aortic valve regurgitation.     

Thallium-201 myocardial perfusion imaging in aortic valve stenosis

The clinical utility of thallium-201 myocardial perfusion imaging in aortic valve stenosis was evaluated at rest and after exercise in three groups of patients: (1) 20 normal subjects, (2) 11 patients with aortic valve stenosis and coronary artery disease (70 percent or greater narrowing of luminal diameter), 11 patients with aortic valve stenosis without coronary artery disease (30 percent or less narrowing). Seven of the latter 22 patients also had postoperative imaging studies. None of the normal subjects had perfusion abnormalities either at rest or after maximal exercise. Three patients with aortic stenosis and coronary artery disease and one with aortic stenosis alone had focal perfusion defects present at rest suggesting prior myocardial infarction. Five patients with aortic stenosis and coronary artery disease manifested new focal perfusion defects and also a pattern of widespread left ventricular wall “thinning” in the postexercise thallium image suggesting diffuse subendocardial ischemia; three had wall “thinning” alone, and two no change in resting focal defects. Five patients with aortic stenosis without coronary artery disease also manifested focal perfusion defects and wall thinning; one had wall thinning alone, and one a new focal defect alone. Two patients had new resting focal defects after surgery, suggesting perioperative damage, and four patients no longer had either the focal or the diffuse pattern of exercise ischemia seen preoperatively.

Thallium-201 imaging is of value in assessing the results of surgery in aortic stenosis. However, the technique does not allow adequate separation of patients with aortic stenosis and coronary artery disease from those with aortic stenosis alone because (1) angiographically significant coronary artery disease may not always produce focal ischemia before diffuse subendocardial ischemia develops, and (2) angiographically insignificant coronary artery disease may become functionally critical in the presence of aortic stenosis and produce focal ischemia.     

Coronary artery surgery in patients with myxoedema

Thyroid replacement therapy in patients with myxoedema associated with coronary atherosclerosis often exacerbates angina or occasionally precipitates myocardial infarction. Coronary revascularization has been proposed for these patients. In an attempt to evaluate the risks of anesthesia and surgery in hypothyroidism against the possible occurrence of a coronary event during preoperative thyroid replacement therapy, we reviewed the literature and report an additional five hypothyroid patients undergoing coronary bypass grafting without operative complications. It seems recommendable not delay thyroid replacement therapy in hypothyroid patients, who need coronary artery surgery, until a few days after the intervention.     

Left Ventricular Response to Isometric Exercise in Aortic Valve Diseases and Its Value in the Optimal Timing of Aortic Valve Replacement

ABSTRACT In order to evaluate the left ventricular response to isometric exercise in different types of aortic valve disease, isometric exercise tests were performed during cardiac catheterization in 14 patients with pure aortic stenosis, 20 with combined aortic stenosis and regurgitation, and 18 with pure aortic regurgitation. Patients with angina pectoris in whom coronary angiography had not been performed were excluded. Thirty-seven patients were recatheterized 12 months after aortic valve replacement, and the ventricular response to exercise was re-evaluated. Preoperatively, the ejection fraction did not change significantly during excercise in patients with aortic stenosis, tended to decrease in patients with combined valve lesion, and decreased significantly in patients with aortic regurgitation (p<0.001). In the three patients whose ejection fraction during preoperative exercise decreased to below 0.40, it remained below 0.50 after successful aortic valve replacment. It appears possible to reveal left ventricular dysfunction in many patients with aortic regurgitation and in some with combined aortic valve disease by means of isometric exercise. The severely depressed ventricular dysfunction during exercise does not appear to correct totally after surgery.     

Angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis

BACKGROUND: Angina pectoris has long been recognised as one of the principal symptoms of severe aortic valve stenosis (AS), even in patients without significant coronary artery disease (CAD). However, controversy exists concerning the prevalence of angina pectoris and associated CAD in such patients. OBJECTIVE: To determine the prevalence of CAD detectable by angiography and its relation to angina pectoris and coronary risk factors in patients with severe AS. PATIENTS AND METHODS: All patients with symptomatic AS who had undergone aortic valve replacement and preoperative cardiac catheterisation at the Austin and Repatriation Medical Centre between 1 January 1986 and 31 May 1996 were retrospectively analysed. Those patients with multiple valve disease, aortic regurgitation of grade 2 or more in severity, or who had had prior coronary artery or valve surgery were excluded from this analysis. RESULTS: A total of 328 consecutive patients with severe AS (242 men and 86 women; mean age 72 years, range 39-84 years) were studied. Significant CAD (reduction in luminal diameter > or = 50%) was found in 162 patients (49.4%). Typical angina was present in 74.7% of these 162 patients but it was also found in 44.6% of the 166 patients without obstructive CAD. Of the patients without angina (n = 133), 30.8% had significant CAD. By multivariate logistic regression, we have identified seven significant predictors for CAD among severe AS patients. Five factors increased risk. Expressed as odds ratio with 95% confidence interval, these included: (i) age in years (1.07; 1.04-1.11, P = 0.001); (ii) male gender (2.09; 1.14-3.80, P = 0.016); (iii) angina pectoris (3.19; 1.89-5.37, P < 0.001); (iv) history of myocardial infarction (2.87; 1.38-5.97, P = 0.005); and (v) peripheral vascular disease (2.28; 1.28-4.05, P = 0.005). Factors associated with decreased likelihood of CAD were serum high density lipoprotein (HDL) cholesterol (0.58; 0.34-0.71, P = 0.002) and peak systolic gradient across the aortic valve (0.97; 0.95-0.99, P = 0.0113). CONCLUSION: Coronary arteriography can probably be omitted for a patient with severe AS if that patient has no symptoms of angina and has no risk factors known to increase its incidence.     

Sinus of valsalva aneurysms involving both coronary ostia

Sinus of Valsalva aneurysms are a rare cause of angina or myocardial infarction. We describe a patient with unstable angina and massive unruptured aneurysms of both coronary sinuses causing severe distortion of both coronary ostia, to our knowledge not previously reported. This unusual patient underwent aortic valve replacement, ascending aortic repair, and coronary artery bypass. At 11-year follow-up, she had developed severe mitral stenosis and prosthetic aortic valve stenosis. Review of the literature reveals 30 reported cases of Sinus of Valsalva aneurysm complicated by coronary insufficiency or infarction, involving either the left (20 cases) or the right coronary sinus (10 cases). We emphasize the poor outcome of these patients, especially if treated conservatively. © 1993 Wiley-Liss, Inc.