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Ann Thorac Surg 1996;62:1424-1430
© 1996 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, Mayo Clinic and Foundation, Rochester, Minnesota
Accepted for publication June 17, 1996.
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Abstract |
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Methods. Between March 1975 and December 1994, 145 patients had AVR after previous CABG. Sixty-three patients (43%) had their initial CABG elsewhere. Reoperation for AVR was the second cardiac procedure in 137 patients and the third in 8. Redo CABG with AVR was done in 66 (46%). There were 118 men and 27 women. The mean age at CABG was 64 ± 7.9 years; for AVR this was 71 ± 7.6 years.
Results. In 2 young patients accelerated calcific aortic stenosis occurred in the setting of renal failure. Significant aortic stenosis did not appear to be addressed at initial CABG in 3 patients. Transaortic valvular gradient, as measured by cardiac catheterization, increased by 10.4 ± 7.0 mm Hg/y. Twenty-four patients (16.6%) died. The mortality for AVR alone or for AVR + redo-CABG was 15 of 125 patients (12%). For patients having more complicated procedures, the mortality was 9 of 20 (45%). Nine patients (6.2%) suffered a postoperative cerebrovascular accident. Low preoperative ejection fraction measured by echocardiography, sternal reentry problems, complexity of operation, and prolonged cross-clamp and bypass times were significant factors associated with mortality. Age at AVR, interval between operations, the extent of underlying native coronary artery disease, the state of the previously placed bypass conduits, and methods of myocardial preservation were not significant predictors of operative mortality. On multivariate analysis there was only one significant value: prolonged cross-clamp time.
Conclusions. Aortic valve replacement after previous CABG is associated with a mortality that is higher than that seen after repeat CABG or repeat AVR. It seems prudent, therefore, to use liberal criteria for AVR in those patients who require coronary revascularization and who, at the same time, have mild or moderate aortic valve disease.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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2 test for categoric variables and by the rank sum test for continuous variables. A multivariate analysis using logistic regression was done on variables found significant by univariate analysis. Procedures were regarded as less complex if AVR was done either alone, with an outflow tract-enlarging procedure (annulus or root enlargement or septal myectomy), or combined with CABG. Other complicated combined procedures were regarded as more complex. |
Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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). Five patients had two previous myocardial revascularization procedures, one of which was a right coronary endarterectomy together with a Vineberg procedure. One patient had CABG followed 12 years later by replacement of the ascending aorta for dissection. Seven patients had mitral and tricuspid procedures before CABG and, in 3 of these patients, previous valvular procedures had been undertaken. Therefore, reoperation for AVR was the second cardiac procedure in 137 patients and the third in 8.
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. The mean age at CABG was 64 ± 7.9 years, and the mean age at AVR was 71 ± 7.7 years. Two patients had the aortic valve inspected at the time of initial CABG. In the intervening period to AVR, 5 patients had a total of 10 percutaneous aortic balloon valvuloplasties. Three of these were done in a short period before AVR, when the patients had pulmonary edema and required intraaortic balloon support [4]. Four patients had five percutaneous coronary angioplasty procedures before AVR.
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). There were 6 patients with aortic dissections. Clinical features of aortic stenosis were present in 100 patients, aortic regurgitation in 15, and mixed aortic valve disease in 30. The mitral valve was free of functional abnormality in 121 patients, 3 patients had features of mitral stenosis, and 21 had evidence of mitral regurgitation. The tricuspid valve was normal in 139 patients, 1 patient had tricuspid regurgitation, and there were features of mixed tricuspid valve disease in 5 patients.
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To assess progression of the disease, the change in gradient between two similar investigational techniques (cardiac catheterization or two-dimensional echocardiography), when this was performed, was divided by the time interval between the procedures. Details of this group are summarized in Table 4, but are limited by the substantial number of procedures done elsewhere (32 of 60 patients, 53%). The average increase in gradient in 39 patients (measured at cardiac catheterization) was 10.4 ± 7.0 mm Hg/y (Table 4).
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Surgical Procedure
EXPOSURE AND BYPASS.
The majority of patients (143) underwent redo sternotomy. Reentry problems occurred in 23 patients (16%). Two patients had arrest during anesthesia. Damage to the following structures occurred during dissection or on reopening: previously inserted grafts, 13 patients; right atrium, 2; innominate vein, 3; pulmonary artery, 1; aorta, 1; and right ventricle, 1. Two patients underwent left thoracotomy and placement of a left ventricular–aortic conduit. In these patients the pulmonary artery was used for venous drainage and the external iliac artery or femoral artery for arterial return. The ascending aorta was cannulated in 120 patients, the femoral artery in 24, and the iliac artery in 1. Total bypass time was 126 ± 52 minutes (range, 0 to 300 minutes), and cross-clamp time was 73 ± 30 minutes (range, 0 to163 minutes).
MYOCARDIAL PROTECTION.
Most patients were managed with moderate hypothermia (24.3 ± 4.6°C; range, 18 to 37°C). One patient underwent deep hypothermia and circulatory arrest. Myocardial protection depended on anatomic findings at operation and the surgeon's preference. Seventy-five patients received crystalloid cardioplegia and 68 received blood cardioplegia. Antegrade cardioplegia was administered in a variety of ways. In patients with aortic stenosis, it was usually given into the aortic root initially and then later into the native coronary ostia and previously inserted grafts. A number of old vein grafts were transected, or small venotomies were made, to provide access for cardioplegic cannulas. Cardioplegic solution was also administered into newly inserted grafts. Occasionally, to gain access to the old ostia, a trapdoor-type incision was made in the ascending aorta to expose, by everting the aorta, the ostia of the old grafts. In the 37 patients with 42 patent internal thoracic arteries, the pedicles were occluded with a bulldog clamp in 13 patients. The artery was left perfusing in 14 patients. Details of internal thoracic artery management in 10 patients was not recorded. In patients with aortic regurgitation, cardioplegic solution was usually infused directly into the native and graft ostia after the aorta was opened.
OPERATIVE PROCEDURES.
One hundred forty-three patients underwent AVR and 2 patients had left ventricular apical aortic conduits placed. The majority of patients (85 of 145, 59%) received tissue valves (Table 5). One patient had a portion of the ascending aorta replaced for atheromatous disease. One patient with endocarditis had a pericardial patch closure of an aortic root abscess. Enlargement of the aortic annulus and root using a pericardial patch was performed in 16 (11%) of the patients. A septal myectomy was done in 6 patients. Additional valvular procedures are listed in Table 5.
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Hospital Mortality
Twenty-four (17%) patients died within 30 days of operation or during the same hospitalization. In the less complex group of patients who underwent AVR alone (7 of 59) or AVR + CABG (8 of 66), the operative mortality was 15 of 125 patients (12%). In the more complex group 9 of 20 patients (45%) died.
The most common cause of death was low cardiac output (18 of 24, 75%). Ten of these patients could not be weaned from bypass. The remaining 8 patients died later of multiorgan failure, also associated with low cardiac output. Of the remaining 6 patients, 2 died suddenly on the 7th and 11th postoperative days (presumably attributable to an acute arrhythmia); both patients with ventricular aortic conduits died, one of a ruptured aorta on day 25 and the other with Wegener's granulomatosis, diabetes mellitus, and multiorgan failure; 1 patient died of a right ventricular laceration at sternal reentry; and another died of bacterial endocarditis.
A large number of preoperative and operative variables were studied to determine risk factors for operative death (Table 6). However, because of a large amount of missing data, particularly pre-CABG data, many of these variables have not been listed. On univariate analysis, factors predictive of operative mortality were prolonged cross-clamp time (p = 0.003) and bypass time (p = 0.005), complex operation (p = 0.001), ejection fraction less than 0.45 on echocardiogram (p = 0.03), and reentry problems (p = 0.07). There was a trend toward a higher mortality in women and in patients with heart failure or in whom no left internal thoracic artery was used at the original operation. Methods of myocardial protection or the state of previously placed vein grafts did not influence operative mortality. On multivariate analysis done with a full model, stepwise model, and backward model using logistic regression there was only one significant value: cross-clamp time.
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. Fifty-nine (44%) of patients had an uncomplicated postoperative course. An intraaortic balloon pump was used in 27 (19%); 10 of these patients died. Nine (6.2%) patients suffered a perioperative cerebrovascular accident.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Is is clear from several studies [10–15] that aortic stenosis will progress at a rate of 5 to 10 mm Hg/y [1, 11, 12], with a concomitant decrease of aortic valve area of approximately 0.08 to 0.1 cm2/y [1, 10, 12, 15]. However, it is difficult to predict for an individual patient [10, 15]. Faggiano and colleagues [10] found no significant relationship between the rate of progression and clinical features such as age, sex, duration of follow-up, and symptomatic status. However, patients with reduced left ventricular function had a higher rate of progression [10]. Wagner and Selzer [14] found similar results and hypothesized that a reduction in left ventricular performance will reduce the aortic valve opening force. Others [15, 16] have found that development of symptoms identified patients with a higher rate of progression. Peter and colleagues [11] compared patients with a rapidly progressive stenosis, as defined by an increase in the maximum pressure gradient greater than 10 mm Hg/y, with patients progressing at a slower rate. Patients progressing rapidly were significantly older and more often had concomitant coronary artery disease than patients with slowly progressive aortic stenosis. Because both coronary artery disease and degenerative aortic stenosis are similar degenerative processes associated with cell proliferation and calcification of vascular tissue, this may reflect a similar aging process affecting blood vessels and valvular tissue. Similarly, diabetes and hypercholesterolemia have been associated with the prevalence of aortic stenosis, suggesting a role for these factors in both coronary artery disease and aortic stenosis [11]. In the context of coronary artery disease, where symptoms may be similar to those of aortic valve disease and myocardial function may be depressed because of ischemia or previous ischemic events, the difficulties of using these modalities as markers of progression or underlying severity of aortic stenosis is obvious.
A hypothetical 70-year-old patient with an initial aortic valve area of 1.4 cm2, a mean gradient of 14 mm Hg, and triple-vessel disease requiring surgical revascularization may have a 5-year expected survival of 87% [17, 18]. After 5 years, the aortic stenosis may have progressed to a critical stage with a mean gradient greater than 60 mm Hg and an aortic valve area of 0.7 cm2. Although we cannot predict with certainty the ultimate outcome for any individual patient, we believe that an aggressive approach to the aortic valve at initial CABG should be followed. Although aortic valve decalcification was previously considered applicable to such patients with mild aortic stenosis undergoing CABG, the results of this procedure have been disappointing [9]. In our experience, a significant number of these patients have returned for subsequent reoperation. These patients were not included in our analysis as the purpose of this study was to review those patients in whom the aortic valve disease was either missed or ignored at initial operation or in whom significant aortic valve disease had developed subsequent to CABG.
We are not able to determine from our data what thresholds should be used to determine AVR in patients undergoing CABG. Factors such as age, urgency of operation, left ventricular function, body surface area, and sex most probably should be considered and individualized before concomitant AVR. An aggressive approach should apply to the young patient with good left ventricular function undergoing elective revascularization. The underlying aortic valve pathology may also influence the decision whether to replace the aortic valve at the time of CABG. Progression of rheumatic or congenital aortic stenosis [19] may be slower than that of degenerative valvular disease, particularly in the older age group with associated coronary artery disease. However, others [19] may argue that valve replacement at the time of CABG is the correct option because of the progressive nature of the abnormal congenital bicuspid aortic valve.
The risk of AVR after previous CABG is not inconsiderable. Avendano and colleagues [3], in an abstract, reported a mortality of 18%. However, in this series 37% of the patients had had previous AVR as well as CABG. After exclusion of previous valve replacement and aortic dissection patients, these same investigators had a mortality of 14% [2]. Collins and co-workers [1] also reported a significant mortality of 18%. Because most of the deaths reported by Fighali and colleagues [2] and the deaths seen in our series were related to complications of low cardiac output, myocardial protection would seem to be of major importance. Patients requiring AVR after previous CABG are particularly at risk because of older age and the presence of left ventricular hypertrophy and myocardial ischemia due to severe coronary artery disease, as well as graft disease. The higher mortality in patients with poor ejection fraction, as well as heart failure, would appear to confirm this. Additional problems include that of reentry, ability to deliver cardioplegia, and management of previously placed grafts. In an effort to place the mortality in perspective we have listed in Table 8 the mortality for primary and reoperation for AVR with and without CABG. As much as possible, results include those published from our own institution; where our results are not available, recently published results of large series from other institutions or from The Society of Thoracic Surgeons data base are included.
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The decision to place a mechanical versus a bioprosthetic valve should be dictated by the usual criteria. Although most of our patients received a bioprosthetic valve, we believe that the indications to use a mechanical valve should be more liberal, because of their greater durability and less need for subsequent reoperation. On the other hand, there is some evidence that porcine xenografts last longer in patients with coronary artery disease [23].
Limitations of this study include its retrospective nature and the fact that details of the earlier operation of CABG in many of the patients who had this procedure elsewhere are missing. Many investigations, particularly echocardiography, were performed during a period of evolution and were not uniformly obtained, making analysis difficult. We would have liked to have given thresholds of determining AVR in patients undergoing CABG. However, to be more specific we would need to know the denominator, that is, the number of patients with mild aortic stenosis who have had CABG who are in the community and who do or do not require AVR. This study is considerable and needs to be done. Because of few events, the multivariate models are considered to be unstable and therefore lack power and are unreliable.
In conclusion, in determining whether the patient with mild aortic valve disease having CABG should have the aortic valve replaced, the following should be considered: (1) the natural history of degenerative aortic valve disease; (2) complications of an implanted prosthetic valve; (3) the natural history of a patient having CABG; (4) the risk of primary AVR + CABG; and, most important, (5) the risk of reoperation for AVR in a patient who is now older after previous CABG.
The definitive study of the efficacy of a surgical procedure is a prospective, randomized trial, and it may be argued that this is necessary before making any conclusions regarding whether the patient with mild aortic valve disease should or should not have the aortic valve replaced at the time of CABG. We and others have demonstrated that there is substantial risk with AVR after previous CABG. Therefore, we believe that a prospective, randomized trial is unnecessary. Most of the mortality and morbidity of the procedure are associated with complex operations, low ejection fraction, and low cardiac output, all of which suggests that myocardial preservation is of critical concern. These patients at reoperation are extremely heterogeneous with a wide spectrum of native coronary and graft disease, variations in vessel operability, and different degrees of aortic stenosis and ventricular hypertrophy. In our analysis, although techniques and methods of cardioplegic delivery did not influence mortality, myocardial preservation clearly needs to be individualized. In most cases systemic hypothermia with a combination of retrograde and antegrade blood cardioplegia would appear to be the best option.
The natural history of degenerative aortic valve disease is progressive, and it is reasonable to assume that the gradient will increase by approximately 10 mm Hg/y. Present generation bioprosthetic [24] and mechanical valves in the older patient demonstrate excellent long-term results with a low morbidity. Therefore, it appears logical to recommend that the threshold for AVR in patients requiring CABG should be lowered because the subsequent risk of reoperation for AVR is higher and outweighs the risk of a prosthetic valve and its subsequent complications.
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Acknowledgments |
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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K. A. Eagle, R. A. Guyton, R. Davidoff, G. A. Ewy, J. Fonger, T. J. Gardner, J. P. Gott, H. C. Herrmann, R. A. Marlow, W. C. Nugent, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: A report of the American College of Cardiology/ American Heart Association task force on Practice Guidelines (Committee to revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery) J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1262 - 1347. [Full Text] [PDF]
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O. Reuthebuch, M. Roth, W. Skwara, W.-P. Klovekorn, and E. P. Bauer Cardioscopy: potential applications and benefit in cardiac surgery Eur. J. Cardiothorac. Surg., June 1, 1999; 15(6): 824 - 829. [Abstract] [Full Text] [PDF]
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T. M. Sundt III, S. F. Murphy, B. Barzilai, R. B. Schuessler, E. N. Mendeloff, C. B. Huddleston, M. K. Pasque, and W. A. Gay Jr Previous Coronary Artery Bypass Grafting Is Not a Risk Factor for Aortic Valve Replacement Ann. Thorac. Surg., September 1, 1997; 64(3): 651 - 657. [Abstract] [Full Text]
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