Perioperative Risk of Aortic Valve Replacement After Coronary Artery Bypass Grafting

Abstract

Objective: To evaluate the operative risk of aortic valve replacement (AVR) after coronary artery bypass grafting (CABG). Methods: Twenty patients (sixteen male, four female) underwent AVR 1.5 - 20 years (mean: 8.2) after CABG. Results: Patients had received a mean number of four bypass grafts (2 - 5) with the use of the left internal thoracic artery in seventeen patients. Mean age at the time of AVR was 70.5 years (57 - 82). All patients suffered from an aortic stenosis with a mean orifice area of 0.74 cm² (0.34 - 1.1) and a mean pressure gradient of 52.4 mm Hg (22 - 78). Ten mechanical (mean diameter 23.6 mm, 21 - 27) and ten biological (22.1 mm, 19 - 25) prostheses were implanted. Mean duration of surgery, cardiopulmonary bypass (CPB) and cross-clamp time were 322.1 (205 - 645), 169.2 (87 - 411), and 77.1 (46 - 128) minutes, respectively. Fourteen patients had an uneventful postoperative course. A temporary neurological impairment, renal failure, and re-intubation for respiratory insufficiency for nine hours occurred in one patient each. Two patients died postoperatively (day 3 and 10) due to multiple cerebral infarctions. One patient required a replacement of the ascending aorta in deep hypothermia and re-implantation of the bypasses. He suffered from gastrointestinal bleeding on postoperative day 14 and expired on day 81 because of multi-organ failure. Conclusion: Aortic valve replacement after coronary artery bypass grafting is associated with an enhanced perioperative risk requiring meticulous decision-making and a sophisticated operative technique.

Key words

Aortic valve replacement - coronary artery bypass grafting - reoperation

References

• 1 Byrne J G, Aranki S F, Couper G S, Adams D H, Allred E N, Cohn L H. Reoperative aortic valve replacement: partial upper hemisternotomy versus conventional full sternotomy.  J Thorac Cardiovasc Surg. 1999;  118 991-997
• 2 Christiansen S, Stypmann J, Tjan T DT. et al . Minimally-invasive versus conventional aortic valve replacement - perioperative course and mid-term results.  Eur J Cardiothorac Surg. 1999;  16 647-652
• 3 Christiansen S, Tjan T DT, Schmid C, Scheld H H. Minimal-invasiver Aortenklappenersatz mit Erweiterungsplastik des Aortenanulus nach Manouguian.  Z Herz Thorax Gefäßchir. 1997;  11 195-197
• 4 Hirose H, Gill I S, Lytle B W. Redo-aortic valve replacement after previous bilateral internal thoracic artery bypass grafting.  Ann Thorac Surg. 2004;  78 782-785
• 5 Hoff S J, Merrill W H, Stewart J R, Bender H W. Safety of remote aortic valve replacement after prior coronary artery bypass grafting.  Ann Thorac Surg. 1996;  61 1689-1692
• 6 Byrne J G, Karavas A N, Filsoufi F. et al . Aortic valve surgery after previous coronary artery bypass grafting with functioning internal mammary artery grafts.  Ann Thorac Surg. 2002;  73 779-784
• 7 Savitt M A, Singh T, Agrawal S, Choudhary A, Chaugle H, Ahmed A. A simple technique for aortic valve replacement in patients with a patent left internal mammary artery bypass graft.  Ann Thorac Surg. 2002;  74 1269-1270
• 8 Vricella L A, Reitz B A. Reoperative aortic valve replacement with patent internal thoracic artery and venous grafts.  Ann Thorac Surg. 2003;  75 637
• 9 Ueda T, Kawata T, Sakaguchi H. et al . Aortic valve replacement in a patient with a patent internal thoracic artery graft.  Ann Thorac Surg. 2004;  77 718-720
• 10 Odell J A, Mullany C J, Schaff H V, Orszulak T A, Daly R C, Morris J J. Aortic valve replacement after previous coronary artery bypass grafting.  Ann Thorac Surg. 1996;  62 1424-1430
• 11 Fiore A C, Swartz M T, Naunheim K S. et al . Management of asymptomatic mild aortic stenosis during coronary artery operations.  Ann Thorac Surg. 1996;  61 1693-1698
• 12 Hochrein J, Lucke J C, Harrison J K. et al . Mortality and need for reoperation in patients with mild-to-moderate asymptomatic aortic valve disease undergoing coronary artery bypass graft alone.  Am Heart J. 1999;  138 791-797
• 13 Kalmar P, Irrgang E. Cardiac surgery in Germany during 2002: A report by the German Society for Thoracic and Cardiovascular Surgery.  Thorac Cardiov Surg. 2003;  51 25-29
• 14 Ahmed A AM, Graham A NJ, Lovell D, O'Kane H O. Management of mild to moderate aortic valve disease during coronary artery bypass grafting.  Eur J Cardiothorac Surg. 2003;  24 535-540
• 15 Collins J J, Aranki S F. Management of mild aortic stenosis during coronary artery bypass graft surgery.  J Card Surg. 1994;  9 (Suppl) 145-147
• 16 Lung B, Gohlke-Bärwolf C, Tornos P. et al . Recommendations on the management of the asymptomatic patient with valvular heart disease.  Eur Heart J. 2002;  23 1253-1266
• 17 Otto C M. Aortic stenosis: Even mild disease is significant.  Eur Heart J. 2004;  25 185-187
• 18 Bonow R O. for the Task Force on Practice Guidelines of the ACC/AHA . Guidelines for the management of patients with valvular heart disease.  JACC. 1998;  32 1486-1588