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- Title
Untreated aortic valve stenosis identified at the time of coronary artery bypass grafting: thresholds associated with adverse prognosis.
- Authors
Thalji, Nassir M.; Suri, Rakesh M.; Enriquez-Sarano, Maurice; Gersh, Bernard J.; Huebner, Marianne; Dearani, Joseph A.; Burkhart, Harold M.; Zhuo Li; Greason, Kevin L.; Michelena, Hector I.; Schaff, Hartzell V.
- 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.
- Subjects
AORTIC stenosis; CORONARY artery bypass; AORTIC valve transplantation; HEALTH outcome assessment; PROPORTIONAL hazards models; PATIENTS
- Publication
European Journal of Cardio-Thoracic Surgery, 2015, Vol 47, Issue 4, p712
- ISSN
1010-7940
- Publication type
Article
- DOI
10.1093/ejcts/ezu231