Coronary Artery Disease and Outcomes of Aortic Valve Replacement for Severe Aortic Stenosis

Abstract

Objectives We contrast risk profiles and compare outcomes of patients with severe aortic stenosis (AS) and coronary artery disease (CAD) who underwent aortic valve replacement (AVR) and coronary artery bypass grafting (AS+CABG) with those of patients with isolated AS who underwent AVR alone. Background In patients with severe AS, CAD is often an incidental finding with underappreciated survival implications. Methods From 10/1991–7/2010, 2,286 patients underwent AVR+CABG and 1,637 AVR alone. A propensity score was developed and used for matched comparisons of outcomes (1,082 patient pairs). Analyses of long-term mortality were performed for each group, then combined to identify common and unique risk factors. Results Patients with AS+CAD vs. isolated AS were older, more symptomatic, more likely to be hypertensive, had lower ejection fraction and greater arteriosclerotic burden, but less severe AS. Hospital morbidity and long-term survival were poorer (43% vs. 59% at 10 years). Both groups shared many mortality risk factors; however, early risk among AS+CAD patients reflected effects of CAD; late risk reflected diastolic left ventricular dysfunction expressed as ventricular hypertrophy and left atrial enlargement. Patients with isolated AS and few comorbidities had the best outcome, those with CAD without myocardial damage had intermediate outcome equivalent to propensity-matched isolated AS patients, and those with CAD, myocardial damage, and advanced comorbidities had the worst outcome. Conclusions Cardiovascular risk factors and comorbidities must be considered in managing patients with severe AS. Patients with severe AS and CAD risk factors should undergo early diagnostics and AVR+CABG before ischemic myocardial damage occurs.

Significance of Coronary Artery Disease and Left Ventricular Afterload in Unoperated Asymptomatic Aortic Stenosis

“…However, patients in that study who underwent AVR and coronary artery bypass graft for AS and CAD without evidence of myocardial damage had outcomes that were equivalent to propensity-matched isolated AS patients who underwent AVR. 13 In addition, the present study demonstrated that CAD was an independent risk factor for cardiovascular events in unoperated patients with asymptomatic AS. Therefore, asymptomatic patients with severe AS and CAD may need to undergo an early aortic valve intervention before myocardial damage occurs.…”

“…A study by Beach and colleagues 13 showed that patients with AS and CAD had worse short-and long-term prognoses and more postoperative morbidity than those with isolated AS. However, patients in that study who underwent AVR and coronary artery bypass graft for AS and CAD without evidence of myocardial damage had outcomes that were equivalent to propensity-matched isolated AS patients who underwent AVR.…”

“…4 Patients with a past history of myocardial infarction and surgical AVR were also excluded. At study entry, clinical data, including coronary artery disease (CAD), which was defined as at least 1 epicardial artery with at least 50% stenosis or a history of percutaneous coronary intervention, 13 were retrieved from the hospital database. This study was approved by the institutional review boards and all patients gave written informed consent.…”

Incidence and severity of atherosclerotic cardiovascular artery disease in patients undergoing TAVI

“…Consequently, coronary artery disease (CAD) as well as carotid artery disease and peripheral artery diseases are often found concurrently in elderly patients presenting with severe symptomatic AS undergoing TAVI. Presence of CAD was demonstrated to negatively affect prognosis in patients undergoing aortic valve replacement and TAVI and was consequently evaluated in the most commonly used surgical risk scores [7,8]. Moreover, the coexistence of carotid and peripheral artery diseases not only further increases risk, but influences also technical approaches since all centers adopted a policy of using the transfemoral approach first, with criteria for the use of non-transfemoral approaches that were based on the size and degree of tortuosity, calcifications, and atheroma of the aorto-iliofemoral arterial tree, as assessed by the multidisciplinary team.…”

Severe aortic stenosis with preserved ejection fraction and evidence of impairment in structure, myocardial strain and ventricular function: A new contribution to clinical decision making

“…The presence of fibrosis and myocyte changes together with an elevation in left ventricular (LV) end-diastolic pressure (LVEDP) or systolic function impairment reduce postoperative survival [8][9][10][11]. Hence, it could be useful to detect myocardial impairment in order to make therapeutic decisions before actual myocardial damage occurs.…”