Untreated aortic valve stenosis identified at the time of coronary artery bypass grafting: Thresholds associated with adverse prognosis

Nassir M. Thalji, Rakesh M. Suri, Maurice E Sarano, Bernard J. Gersh, Marianne Huebner, Joseph A. Dearani, Harold M. Burkhart, Zhuo Li, Kevin L. Greason, Hector I Michelena, Hartzell V Schaff

Research output: Contribution to journalArticle

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Abstract

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.

Original languageEnglish (US)
Article numberezu231
Pages (from-to)712-719
Number of pages8
JournalEuropean Journal of Cardio-thoracic Surgery
Volume47
Issue number4
DOIs
StatePublished - Apr 1 2015

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Aortic Valve Stenosis
Coronary Artery Bypass
Aortic Valve
Mortality
Confidence Intervals
Survival
Peripheral Vascular Diseases
Proportional Hazards Models
Creatinine
Heart Failure
Clinical Trials

Keywords

  • Aortic stenosis
  • Bypass surgery
  • Prognosis

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery
  • Pulmonary and Respiratory Medicine

Cite this

Untreated aortic valve stenosis identified at the time of coronary artery bypass grafting : Thresholds associated with adverse prognosis. / Thalji, Nassir M.; Suri, Rakesh M.; Sarano, Maurice E; Gersh, Bernard J.; Huebner, Marianne; Dearani, Joseph A.; Burkhart, Harold M.; Li, Zhuo; Greason, Kevin L.; Michelena, Hector I; Schaff, Hartzell V.

In: European Journal of Cardio-thoracic Surgery, Vol. 47, No. 4, ezu231, 01.04.2015, p. 712-719.

Research output: Contribution to journalArticle

Thalji, Nassir M. ; Suri, Rakesh M. ; Sarano, Maurice E ; Gersh, Bernard J. ; Huebner, Marianne ; Dearani, Joseph A. ; Burkhart, Harold M. ; Li, Zhuo ; Greason, Kevin L. ; Michelena, Hector I ; Schaff, Hartzell V. / Untreated aortic valve stenosis identified at the time of coronary artery bypass grafting : Thresholds associated with adverse prognosis. In: European Journal of Cardio-thoracic Surgery. 2015 ; Vol. 47, No. 4. pp. 712-719.
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abstract = "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.",
keywords = "Aortic stenosis, Bypass surgery, Prognosis",
author = "Thalji, {Nassir M.} and Suri, {Rakesh M.} and Sarano, {Maurice E} and Gersh, {Bernard J.} and Marianne Huebner and Dearani, {Joseph A.} and Burkhart, {Harold M.} and Zhuo Li and Greason, {Kevin L.} and Michelena, {Hector I} and Schaff, {Hartzell V}",
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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 - Sarano, Maurice E

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

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

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