Ann Thorac Surg 2009;87:1749-1750. doi:10.1016/j.athoracsur.2009.03.016
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited commentary
Cary W. Akins, MD
Cardiac Surgery Division, Massachusetts General Hospital, Cardiac Surgery—Cox 648, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114
(Email: cakins{at}partners.org).
Of the four left-sided valvular lesions treated with valve replacement, aortic valve replacement for severe aortic stenosis yields the best early and late results. After removal of the obstruction to the left ventricular outflow, the heart is almost immediately better, in part because the ventricle has been preconditioned to generate higher pressures. Thus, there are few contraindications to valve replacement for severe aortic stenosis.
Hannan and colleagues [1], using the New York State cardiac surgery database, identified risk factors that impact mortality and generated survival statistics for those with and without the important risk factors and compared those results with the general population. None of the risk factors identified and compared (including advanced age, recent acute myocardial infarction, congestive heart failure, diminished ejection fraction, and hemodynamic instability) are actually surprising, although the degree of their impact is more clearly defined.
This study, sufficiently powered with 6,369 patients, substantiates the risk associated with concomitant myocardial revascularization. For decades cardiac surgeons have known, or at least believed, that the addition of coronary artery bypass grafting to aortic valve replacement has a deleterious impact on survival. As I have previously written [2], this impact is at first glance not easy to explain. Numerous studies have documented that the mid-term survival of isolated coronary artery bypass patients is essentially equivalent to that of the general population. Therefore, one might suspect that adding concomitant myocardial revascularization to aortic valve replacement would minimally impact mortality, but as this and other studies have demonstrated, this is not the case. The cause of this paradox has not been explained, but may include the combination of coronary artery disease with left ventricular hypertrophy, possibly resulting in increased complications associated with subendocardial ischemia. The poorer results with patients requiring concomitant myocardial revascularization substantiates lowering the threshold age for using bioprostheses, because expected patient survival is not normal in these patients.
This study also provides some credence to earlier valve replacement for severe aortic stenosis before some of the identified risk factors associated with progressive left ventricular dysfunction develop.
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References
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- Hannan EL, Samadashvili Z, Lahey SJ, et al. Aortic valve replacement for patients with severe aortic stenosis: risk factors and their impact on 30-month mortality Ann Thorac Surg 2009;87:1741-1750.[Abstract/Free Full Text]
- Akins CW, Hilgenberg AD, Vlahakes GJ, MacGillivray TE, Torchiana DF, Madsen JC. Results of bioprosthetic versus mechanical aortic valve replacement performed with concomitant coronary artery bypass grafting Ann Thorac Surg 2002;74:1098-1106.[Abstract/Free Full Text]
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References