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Ann Thorac Surg 1996;61:1689-1691
© 1996 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Safety of Remote Aortic Valve Replacement After Prior Coronary Artery Bypass Grafting

Department of Cardiac and Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. A previous coronary artery bypass grafting (CABG) procedure may complicate subsequent aortic valve replacement (AVR). However, the operative risks and long-term outcome of patients who undergo these two procedures remain poorly defined.

Methods. The medical records of all patients undergoing AVR between February 1986 and September 1995 were reviewed retrospectively. The patients selected for analysis had previously undergone CABG.

Results. We performed AVR in 23 consecutive patients who had previously undergone CABG (mean number of grafts, 2.8). The AVR was performed an average of 7.6 years after CABG (range, 2 to 17 years). There were 20 men and 3 women, with a mean age of 69 years (range, 56 to 85 years). Twenty patients were operated upon for aortic stenosis (mean gradient 54 mm Hg, mean valve area 0.7 cm²), and 3 patients underwent operation for aortic regurgitation. The average aortic valve gradient at the initial revascularization operation was 8 mm Hg (range, 0 to 29 mm Hg). There was no correlation between the aortic valve gradient at the initial revascularization and the interval between CABG and AVR. At the second operation, AVR was performed alone in 11 patients, combined with repeat CABG in 11 patients (mean number of grafts, 1.4), and with mitral valve replacement in 1 patient. A mechanical prosthesis was selected in 14 patients, and a bioprosthesis was used in 9 patients. There were no perioperative deaths. There were five late deaths at an average follow-up of 44 months. The 5-year actuarial survival was 71%.

Conclusions. Previous CABG poses added technical challenges at the time of reoperation for AVR. The operation can be performed safely, with the expectation of satisfactory long-term survival.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 1691.

A previous coronary artery bypass grafting (CABG) procedure may complicate reoperation for aortic valve replacement (AVR) in many ways. Repeat sternotomy, the handling of patent vein or internal mammary artery grafts, and the need to relocate sites for aortic perfusion, aortic cross-clamping, cardioplegia, and aortotomy because of previously placed bypass grafts all add technical complexity to the procedure and potentially increase perioperative risk [1–3]. These risks are poorly defined in the literature [4, 5]. In addition, the natural history of mild to moderate aortic stenosis or regurgitation in the face of operable coronary artery disease is equally poorly defined [6–9]. These factors complicate the decision regarding replacement of the aortic valve for mild to moderate aortic valve disease at the time of CABG.

In this report, we outline our experience with AVR in patients who have previously undergone CABG. We attempt to define the perioperative morbidity and mortality associated with the procedure, as well as add to the understanding of the natural history of mild to moderate aortic valve disease in patients who have previously undergone myocardial revascularization and who subsequently require replacement of the aortic valve.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The medical records of all patients undergoing AVR between February 1986 and September 1995 at the Vanderbilt University Medical Center and its affiliated Department of Veterans Affairs Nashville Hospital were reviewed retrospectively. The patients selected for analysis underwent AVR during that period and had previously undergone CABG. Twenty-three consecutive patients who met these criteria were identified, and they form the basis for this report. Details of the patients' original CABG operation and their subsequent AVR were extracted from the medical record, as well as the interval between these operations, the nature of the aortic valve disease, all echocardiographic and catheterization data, and all follow-up information.

Actuarial survival was estimated using the method of Kaplan and Meier [10]. All statistical calculations were performed using NCSS statistical software, and significance was set at p less than 0.05.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Between February 1986 and September 1995, we performed AVR in 23 patients who had previously undergone CABG. There were 20 men and 3 women, with a mean age of 69 years (range, 56 to 85 years). At the original CABG operation, the mean number of grafts performed was 2.8 (range, one to five). The internal mammary artery was used in 6 patients. The mean aortic valve gradient at the initial revascularization procedure, when measured, was 8 mm Hg (range, 0 to 29 mm Hg).

At the subsequent AVR, the indication for operation in 20 patients was severe aortic stenosis, with a mean gradient of 54 mm Hg (range, 15 to 103 mm Hg) and a mean valve area of 0.7 cm². Three patients underwent operation for aortic regurgitation. The valve was senile in 17 patients, bicuspid in 2, rheumatic in 1, and regurgitant in 3. The AVR was performed an average of 7.6 years after CABG (range, 2 to 17 years). There was no correlation between aortic valve gradient at the time of initial revascularization and the interval between CABG and AVR. At the second operation, AVR alone was performed in 11 patients, and it was combined with repeat CABG in 11 patients (mean number of grafts, 1.4; range, one to three) and with mitral valve replacement in 1 patient. A mechanical prosthesis was selected in 14 patients, and a bioprosthesis was used in 9 patients. Myocardial protection was accomplished using antegrade cardioplegia alone in 14 patients, whereas combined antegrade and retrograde cardioplegia was used in 9 patients. At the time of repeat coronary arteriography before AVR, 21 of 23 patients had at least one patent bypass graft. Patent vein grafts were handled using a "no-touch" technique. In the 6 patients who had undergone previous CABG using the internal mammary artery, all grafts were patent at the time of reoperation. A limited dissection was carried out to allow clamping of the graft at cardioplegia administration.

There were no perioperative deaths. One patient suffered a perioperative myocardial infarction requiring intraaortic balloon counterpulsation and left ventricular assist. He was discharged after 65 days, but returned 3 months later in congestive heart failure and ultimately required cardiac transplantation 6 months later. He is alive and well 5 years later. One patient had low cardiac output in the immediate postoperative period and required intraaortic balloon counterpulsation and inotropic support for several days. One patient required reexploration for bleeding. One patient was reintubated on the first postoperative day for respiratory insufficiency. One patient had a small stroke; another suffered mild confusion transiently, without radiographic evidence of stroke or clinical evidence of permanent neurologic deficit.

There were five late deaths, with an average follow-up of 44 months. Three patients died of a cardiac cause and 2 of advanced pulmonary disease. The remainder of the patients alive at the end of the study period were in New York Heart Association class I or II. The 5-year actuarial survival was 71% (Fig 1); the median survival was more than 44 months.

View larger version (12K): [in this window] [in a new window]   Fig 1. . Actuarial survival of patients undergoing aortic valve replacement after prior coronary artery bypass grafting.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Our practice during this study was to use standard ascending aortic perfusion and antegrade cardioplegia, with the addition of retrograde cardioplegia in the later years of the study period. We used an oscillating sternal saw for sternal reentry, and we preferred a "no-touch" technique for handling old bypass grafts. In patients with patent internal mammary artery grafts at the time of subsequent AVR, we performed limited dissection of the grafts to allow clamping of the internal mammary artery during aortic cross-clamping.

Based on these considerations, we believed that the operative risk would be increased. On closer examination of the literature, we found that the perioperative morbidity and mortality of AVR after previous CABG were not well characterized. Collins and Aranki [4] reported their experience with AVR in 44 patients who had previously undergone CABG. None of their patients were deemed to have severe aortic stenosis at the original CABG procedure. The interval between CABG and AVR was 68 months, about 2 years shorter than that seen in our experience. In their report, the mean transvalvular gradients increased from 12 mm Hg to 64 mm Hg between the first and second procedures. Their perioperative mortality rate was 18.2% in the entire group, and it was higher in patients who also required repeat CABG than in those patients who required only AVR (22.7% versus 13.6%).

Fiore and colleagues [9] reported a group of 28 patients who underwent AVR after previous CABG and found an operative mortality rate of 18%, compared with 9.1% in a group of patients undergoing combined AVR and CABG. They reported that the 1- and 5-year actuarial survival rates were similar in the two groups of patients.

Several reports in recent years have begun to deal with the management of mild to moderate aortic valve disease at the time of CABG. Antunes [2] suggested that aortic valve repair may be an option at the time of CABG in selected patients with mild to moderate aortic valve disease. Wong and coauthors [8] stated that their inclination is to replace the aortic valve in patients with mild to moderate disease at the time of CABG, but their experience was not sufficient to draw conclusions that reached statistical significance.

Other authors have attempted to document the progression of aortic valve disease, and particularly aortic valve stenosis, in an attempt to predict better which patients may benefit from early AVR and thus be spared early reoperation. In a study of 47 patients over a span of almost 5 years, Ng and colleagues [7] showed a progression of aortic stenosis, with initial aortic valve areas of 1.26 cm² falling to 0.77 cm² over this short interval. Their data suggested that patients with little or no left ventricular impairment or associated coronary artery disease had a more rapid progression of aortic stenosis than did those patients with associated coronary artery disease or severe left ventricular impairment. In their series, they described a small group of 9 patients who went on to require AVR after previous CABG. They observed a mortality rate of 33% for the subsequent AVR. Mohler and coauthors [6] described certain risk factors for atherosclerotic disease that may influence the progression of aortic valve stenosis. Grover and colleagues [5], reporting data from the Veterans Administration Preoperative Risk Assessment Study, also described many risk factors for AVR in a group of higher-risk patients from Veterans Administration hospitals. About half of the patients in this report were from this select patient population. Although these authors did not describe risk factors for reoperative AVR, their study does speak specifically to risk factors that clearly increase the perioperative risk and may be taken into consideration as the surgeon counsels patients in preparation for this type of procedure.

Another factor that the surgeon should consider in treating the patient with mild to moderate aortic stenosis at the time of CABG is the added valve-related morbidity and mortality associated with earlier insertion of a prosthetic aortic valve. This is particularly important in the younger patient in normal sinus rhythm. Because the currently accepted practice is to give anticoagulation therapy to patients in chronic or intermittent atrial fibrillation, these patients being considered for early valve replacement do not incur the added risk associated with long-term anticoagulation regimens.

We conclude that previous CABG may pose added technical challenges at the time of reoperation for AVR. These preliminary data suggest that AVR can be performed safely after a prior CABG procedure, with low perioperative morbidity and mortality rates. In addition, these data suggest that satisfactory long-term results can be achieved in most patients. There appears to be a growing sentiment in the literature to consider AVR at the time of CABG in patients with mild to moderate aortic valve disease. Although that approach deserves careful consideration, we have shown that an antecedent CABG procedure can be followed by AVR with satisfactory results.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Forty-second Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 9-11, 1995.

Address reprint requests to Dr Merrill, Department of Cardiac and Thoracic Surgery, Vanderbilt University School of Medicine, Room 2986 The Vanderbilt Clinic, Nashville, TN 37232-5734.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Sindhi R, Belisle J, Cleveland RJ, Diehl JT. Patch aortotomy for aortic valve replacement after previous coronary artery bypass grafting. Ann Thorac Surg 1991;51:676–7.[Abstract]
2. Antunes MJ. Coronary artery bypass and mild aortic stenosis. To replace or not to replace? An alternative to repair. J Heart Valve Dis 1994;3:235.[Medline]
3. Safi HJ, Iliopoulos DC, Duff DS. Repeat replacement of aortic bioprosthesis. Ann Thorac Surg 1995;59:1217–9.[Abstract/Free Full Text]
4. Collins JJ Jr, Aranki SF. Management of mild aortic stenosis during coronary artery bypass graft surgery. J Cardiac Surg 1994;9(2 Suppl):145–7.[Medline]
5. Grover FL, Hammermeister KE, Burchfiel C. Initial report of the Veterans Administration Preoperative Risk Assessment Study for Cardiac Surgery. Ann Thorac Surg 1990;50:12–28.[Abstract]
6. Mohler ER, Sheridan MJ, Nichols R, Harvey WP, Waller BF. Development and progression of aortic valve stenosis: atherosclerosis risk factors-a causal relationship? A clinical morphologic study. Clin Cardiol 1991;14:995–9.[Medline]
7. Ng AS, Holmes DR Jr, Smith HC, et al. Hemodynamic progression of adult valvular aortic stenosis. Cathet Cardiovasc Diagn 1986;12:145–50.[Medline]
8. Wong PS, Davies SW, Youhana A, Wright JE, Magee PG. Coronary artery bypass surgery and minor aortic stenosis-to replace or not to replace? J Heart Valve Dis 1993;2:649–52.[Medline]
9. Fiore AC, Swartz MT, Naunheim KS, et al. Management of asymptomatic mild aortic stenosis during coronary artery operations. Ann Thorac Surg 1996;61:1693–8.[Abstract/Free Full Text]
10. Kaplan EL, Meier P. Non-parametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–81.

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