TY - JOUR
T1 - Untreated aortic valve stenosis identified at the time of coronary artery bypass grafting
T2 - Thresholds associated with adverse prognosis
AU - Thalji, Nassir M.
AU - Suri, Rakesh M.
AU - Enriquez-Sarano, Maurice
AU - Gersh, Bernard J.
AU - Huebner, Marianne
AU - Dearani, Joseph A.
AU - Burkhart, Harold M.
AU - Li, Zhuo
AU - Greason, Kevin L.
AU - Michelena, Hector I.
AU - Schaff, Hartzell V.
N1 - Funding Information:
This work was funded by the Division of Cardiovascular Surgery of the Mayo Clinic, Rochester, MN, USA.
Funding Information:
Conflict of interest: The Division of Cardiovascular Surgery has a research grant entitled ‘Randomized biological aortic valve replacement’ funded equally by Edwards Lifesciences, St Jude Medical and Sorin Group. Rakesh M. Suri is the Principal Investigator for the PERCEVAL™ IDE trial funded by Sorin Group. Bernard J. Gersh reports serving on the advisory board of Baxter Healthcare Corporation, Boston Scientific, Cardiovascular Research Foundation, InspireMD, PPD Development LP and St Jude Medical. Maurice Enriquez-Sarano reports serving on the advisory board of Valtech, and receiving research funding from Abbott Vascular. All other authors report no disclosures. None of the disclosures pertain to the current investigation.
Publisher Copyright:
© The Author 2014.
PY - 2015/4/1
Y1 - 2015/4/1
N2 - OBJECTIVES: Aortic valve replacement (AVR) for severe aortic valve stenosis (AS) is a Class I indication at the time of coronary artery bypass grafting (CABG). Management of less-than-severe AS in patients undergoing CABG is uncertain however, because the thresholds at which untreated AS impacts long-term outcome are unclear. METHODS: We identified 312 patients who underwent isolated CABG between 1993 and 2006 with mild or moderate AS [aortic valve area (AVA) 1-2 cm2], and matched them to patients undergoing CABG alone during the same period with similar characteristics but without AS (AVA >2 cm2). Long-term survival after CABG and its determinants were analysed using Cox proportional hazards models with AVR as a time-dependent covariate. RESULTS: Late survival was lower in patients with untreated moderate AS (12 years 23 ± 5.1%) versus mild (42 ± 3.8%) or no AS (38 ± 3.3%) (P = 0.01). Adjusting for age, ejection fraction, heart failure, creatinine, diabetes, peripheral vascular disease (PVD) and interval AVR, moderate AS independently predicted higher mortality [hazard rate (HR) 2.01, 95% confidence interval (CI) 1.49-2.73; P < 0.001]; whereas incremental risk was insignificant for patients with mild AS (HR 1.09, 95% CI 0.85-1.66; P = 0.33). Further stratification showed that highest late postoperative mortality occurred with an AVA of 1-1.25 cm2 (adjusted HR 2.45, 95% CI 1.57-3.82; P < 0.001), while risk was intermediate with an AVA of 1.25-1.5 cm2 (HR 1.83, 95% CI 1.28-2.61; P = 0.001). CONCLUSIONS: Untreated moderate AS is an independent determinant of excess late mortality following isolated CABG, and mortality risk increases with decreasing AVA. Those with moderate-to-severe AS (AVA 1-1.25 cm2) have more than 2-fold greater long-term mortality compared with those without AS. These data define AS severity thresholds for clinical trials aimed at defining whether valve intervention might mitigate this risk.
AB - OBJECTIVES: Aortic valve replacement (AVR) for severe aortic valve stenosis (AS) is a Class I indication at the time of coronary artery bypass grafting (CABG). Management of less-than-severe AS in patients undergoing CABG is uncertain however, because the thresholds at which untreated AS impacts long-term outcome are unclear. METHODS: We identified 312 patients who underwent isolated CABG between 1993 and 2006 with mild or moderate AS [aortic valve area (AVA) 1-2 cm2], and matched them to patients undergoing CABG alone during the same period with similar characteristics but without AS (AVA >2 cm2). Long-term survival after CABG and its determinants were analysed using Cox proportional hazards models with AVR as a time-dependent covariate. RESULTS: Late survival was lower in patients with untreated moderate AS (12 years 23 ± 5.1%) versus mild (42 ± 3.8%) or no AS (38 ± 3.3%) (P = 0.01). Adjusting for age, ejection fraction, heart failure, creatinine, diabetes, peripheral vascular disease (PVD) and interval AVR, moderate AS independently predicted higher mortality [hazard rate (HR) 2.01, 95% confidence interval (CI) 1.49-2.73; P < 0.001]; whereas incremental risk was insignificant for patients with mild AS (HR 1.09, 95% CI 0.85-1.66; P = 0.33). Further stratification showed that highest late postoperative mortality occurred with an AVA of 1-1.25 cm2 (adjusted HR 2.45, 95% CI 1.57-3.82; P < 0.001), while risk was intermediate with an AVA of 1.25-1.5 cm2 (HR 1.83, 95% CI 1.28-2.61; P = 0.001). CONCLUSIONS: Untreated moderate AS is an independent determinant of excess late mortality following isolated CABG, and mortality risk increases with decreasing AVA. Those with moderate-to-severe AS (AVA 1-1.25 cm2) have more than 2-fold greater long-term mortality compared with those without AS. These data define AS severity thresholds for clinical trials aimed at defining whether valve intervention might mitigate this risk.
KW - Aortic stenosis
KW - Bypass surgery
KW - Prognosis
UR - http://www.scopus.com/inward/record.url?scp=84926468823&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84926468823&partnerID=8YFLogxK
U2 - 10.1093/ejcts/ezu231
DO - 10.1093/ejcts/ezu231
M3 - Article
C2 - 24906802
AN - SCOPUS:84926468823
SN - 1010-7940
VL - 47
SP - 712
EP - 719
JO - European Journal of Cardio-thoracic Surgery
JF - European Journal of Cardio-thoracic Surgery
IS - 4
M1 - ezu231
ER -