Aortic Valve Replacement and Coronary Artery Surgery: Determinants Affecting Early and Long-Term Results

Abstract

Background: We studied factors influencing early and late results in patients operated on for aortic valve replacement and coronary artery bypass graft. Methods: 175 patients were retrospectively analysed over a 10-year period ending in December 2002. There were 135 males and 40 females with a mean age of 62.7 ± 8.9 years; 109 were in NYHA class III/IV; 45 required an urgent operation, and 103 mechanical valves and 72 biological valves were implanted. Results: There were 11 operative deaths (6.3 %). Statistical analysis (logistic regression) showed that previous myocardial infarction, poor NYHA class, and low LVEF had a significant effect on early death. There were 52 late deaths at a mean follow-up of 82.7 ± 38.8 months. Using a Cox survival analysis for any causes, age, urgent operation, low LVEF, and creatinine had a strong impact on unfavourable late outcome. Conclusions: A combination of a patient-related factor (age), cardiac-related condition (low LVEF), co-morbid condition (renal dysfunction), and operative cause (urgent operation) is the most important predictor of late clinical outcome for this combined surgical procedure.

Key words

Aortic valve replacement - coronary bypass graft - combined procedures - mechanical valves - bioprostheses

References

• 1 Kvidal P, Berström R, Hörte L, Stäle E. Observed and relative survival after aortic valve replacement.  J Am Coll Cardiol. 2000;  35 747-756
• 2 Bloomfield P, Wheatley D J, Prescott R J, Miller H C. Twelve-year comparison of a Bjork-Shiley valve with porcine bioprostheses.  N Engl J Med. 1991;  324 573-579
• 3 Hammermeister K, Sethi G K, Henderson W G, Grover F L, Oprian C, Rahimtoola S H. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affair Randomized Trial.  J Am Coll Cardiol. 2000;  36 1152-1158
• 4 Rahimtoola S H. Choice of prosthetic heart valve for adult patients.  J Am Coll Cardiol. 2003;  41 893-904
• 5 Akins C W, Hilgenberg A D, Vlahakes G J, MacGillivray T E, Torchiana D F, Madsen J C. Results of bioprosthetic versus mechanical aortic replacement performed with concomitant coronary artery bypass grafting.  Ann Thorac Surg. 2002;  74 1098-1106
• 6 Puvimanasinghe J PA, Takkenberg J JM, Eijkemans M JC, Steyerberg E W, van Herwerden L A, Grunkemeier G L, Habbena J DF, Bogers A JJC. Choice of a mechanical valve or a bioprosthesis for AVR: does CABG matter?.  Eur J Cardiothoracic Surg. 2003;  23 688-695
• 7 Jones E J, Weintraub W S, Craver J M, Guyton R A, Shen Y. Interaction of age and coronary disease after valve replacement: implication for valve selection.  Ann Thorac Surg. 1994;  58 378-385
• 8 Cohen G, David T E, Ivanov J, Armstrong S, Feindel C M. The impact of age, coronary artery disease, and cardiac comorbidity on late survival after bioprosthetic aortic valve replacement.  J Thorac Cardiovasc Surg. 1999;  117 273-284
• 9 Edmunds Jr L H, Clark R E, Cohn L H, Grunkemeier G L, Miller D C, Weisel R D. Guidelines for reporting morbidity and mortality after cardiac valvular operations.  Eur J Cardiothoracic Surg. 1996;  10 812-816
• 10 Czer L SC, Gray R J, Stewart M E, DeRobertis M, Chaux A, Matloff J M. Reduction in sudden late death by concomitant revascularization with aortic valve replacement.  J Thorac Cardiovasc Surg. 1988;  95 390-401
• 11 Nunley D L, Grunkemeier G L, Starr A. Aortic valve replacement with coronary bypass grafting. Significant determinants of ten-year survival.  J Thorac Cardiovasc Surg. 1983;  85 705-711
• 12 Magovern J A, Pennock J L, Campbell D B, Pae W E, Bartholomew M, Pierce W S, Waldhausen J A. Aortic valve replacement and combined aortic valve replacement and coronary artery bypass grafting: predicting high risk group.  J Am Coll Cardiol. 1987;  9 38-43
• 13 Nakayama Y, Sakata R, Ura M, Itoh T. Long-term results of coronary artery bypass grafting in patients with renal insufficiency.  Ann Thorac Surg. 2003;  75 496-500
• 14 Flameng W J, Herijers P, Szécsi J, Sergeant P T, Daenen W J, Scheys I. Determinants of early and late results of combined valve operations and coronary artery bypass grafting.  Ann Thorac Surg. 1996;  61 621-628
• 15 Leon M B, Baim D S, Popma J J, Gordon P C, Cutlip D E, Ho K KL, Giambartololei A, Diver D J, Lasorda D M, Williams D O, Pocock S J, Kuntz R E. A clinical trial comparing three antithrombotic-drug regimens after coronary artery stenting.  N Engl J Med. 1998;  339 1665-1671
• 16 Van Nooten G J, Van Belleghem Y, Caes F, Francois K, Van Overbeke H, Bove T, Taeymans Y. Lower-intensity anticoagulation for mechanical heart valves: new concept with the ATS bileaflet aortic valve.  J Heart Valve Dis. 2003;  12 495-501