Ann Thorac Surg 2007;83:978
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Paul Kurlansky, MD
Miami Heart Research Institute, 4770 Biscayne Blvd, Suite 500, Miami, FL 33137
(Email: doctorwu18{at}aol.com).
With an aging population, cardiac surgeons are increasingly confronted with the complex patient with combined aortic valve and coronary artery disease. Given the increased myocardial oxygen demand and diminished supply intrinsic to stenotic aortic valve disease, as well as delicate issues of preservation and reperfusion injury in the hypertrophic ventricle, the surgeon must calculate the incremental benefit of performing bypass grafts in addition to valve replacement, against the potential increase in operative risk engendered. It is specifically in the resolution of this dilemma that the in-depth analysis of Kobayashi and colleagues [1] is so helpful.
Although their analysis bears the common caveats intrinsic to retrospective studies of limited sample size, there are several take-home messages that emerge with clarity. First, even though surgical results in the elderly continue to improve, age itself remains a significant marker of perioperative and long-term mortality. Second, despite these limitations, the operative risk attributable to the time and effort required to pursue a strategy of complete revascularization in a setting of careful myocardial preservation is negligible. Third, provided this strategy is tempered by anatomic limitations only, the potential negative impact of incomplete revascularization is marginalized. Fourth, despite advanced age and ventricular hypertrophy, the strategy of internal mammary artery grafting to the left anterior descending coronary artery remains a viable one. Fifth, despite the higher perioperative mortality and morbidity attained in this elderly cohort, the long-term functional results are excellent with minimal need for repeat revascularization. Finally, although there is no comparison group, the pursuit of this aggressive strategy of revascularization in this elderly cohort essentially removes the extent of coronary disease from the determinants of long-term survival.
To a certain extent, these findings are corroborative of previous surgical experience, but they are particularly noteworthy at this time. As previously mentioned the changing pattern of surgical referrals favoring increasingly elderly and complex patients warrants frequent re-evaluation of accepted paradigms. Perhaps more compelling is the issue of emerging technologies to facilitate percutaneous valvular procedures. The painful lesson that our profession sometimes neglects in its joint enthusiasm with the device industry is that technology does not change the laws of physiology, it merely facilitates one approach or another in dealing with it. Therefore, hopefully we will not need to relearn the value of complete revascularization of the ischemic hypertrophic ventricle in an effort to facilitate the replacement of a stenotic valve or insufficient aortic valves, or a combination of these.
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References
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- Kobayashi KJ, Williams JA, Nwakanma L, Gott VL, Baumgartner WA, Conte JV. Aortic valve replacement and concomitant coronary artery bypass: assessing the impact of multiple grafts Ann Thorac Surg 2007;83:969-978.[Abstract/Free Full Text]
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