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Ann Thorac Surg 1998;66:307-308
© 1998 The Society of Thoracic Surgeons

Correspondence

Reply

Thoralf M. Sundt, III, MDa, William A. Gay, Jr, MDa

a Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA

To the Editor

We thank Dr Dalrymple-Hay and his associates for their interest in and thoughtful comments on the management of mild aortic stenosis at the time of primary coronary artery bypass grafting. We too were surprised by the results of our study [1], although others have previously [2] and subsequently [3] reported only modest mortality risks for aortic valve replacement after previous coronary artery bypass grafting. Although apparent differences in mortality rate may be secondary to differences in patient demographics or other factors, it should be noted that comparison of these rates for our series versus that of Dalrymple-Hay and colleagues by Fisher’s exact tests yields a p value of 0.339 (not significant). Given the small numbers, their results may in fact not be so different from ours.

We agree with Dalyrymple-Hay and colleagues that in practice decisions regarding the optimal management of the mildly stenotic valve are difficult and are influenced on an individual basis by a variety of patient-specific factors. We also agree that the risk of reoperation is only one factor in the risk/benefit equation, and as such should not be put forward in isolation as an argument for or against intervention on such valves at primary operation. As emphasized by Dalrymple-Hay and colleagues, the increased operative risk of aortic valve replacement plus coronary artery bypass grafting over coronary artery bypass grafting alone as well as the risks of valve-related complications must be considered. Equally, both the probability of progression of the stenosis in any individual patient and the rate of that progression are critical and, at present, unknown. A large, prospective study of patients with mild aortic stenosis randomized to valve replacement or expectant therapy would more directly address the question. Without these data clinicians must, of course, tailor their therapy to the individual patient. Algorithms such as that presented by Dalyrymple-Hay and colleagues may serve as guidelines. It must be acknowledged, however, that although they may be rational, without data they are unproven hypotheses.

Our central conclusion with the regard to the mildly stenotic valve was that "routine replacement of mildly stenotic valves is not indicated at this time" [3], a statement by which we stand.

References

  1. Sundt T.M., III, Murphy S., Barzilai B., et al. Previous coronary artery bypass grafting is not a risk factor for aortic valve replacement. Ann Thorac Surg 1997;64:651-658.[Abstract/Free Full Text]
  2. Hoth S.J., Merrill W.H., Stewart J.R., Bender H.W., Jr Safety of remote aortic valve replacement after prior coronary artery bypass grafting. Ann Thorac Surg 1996;61:1689-1692.[Abstract/Free Full Text]
  3. Munoz E., Lytle B., Stewart R., Taylor P., Potts W., Cosgrove D. Reoperation for aortic valve replacement after a previous coronary artery revascularization: is it safe?. Circulation 1997;96(Suppl 1):430.



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This Article
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