DEPARTMENT OF THORACIC & CARDIOVASCULAR SURGERY ST. PAUL ’ S HOSPITAL

DEPARTMENT OF THORACIC &

CARDIOVASCULAR SURGERY

ST. PAUL’S HOSPITAL

THE CATHOLIC UNIVERSITY OF KOREA

CHAN BEOM PARK

SURGICAL STRATEGRY FOR SURGICAL STRATEGRY FOR

CABG WITH ASSOCIATED CABG WITH ASSOCIATED

VALVE SURGERYVALVE SURGERY

대한흉부외과학회 제 24 차 춘계학술대회

Combinded Procedures. In: Surgery of Coronary artery disease, Wheatley DJ. London: Arnold 2003, 326-33.

STS Database STS Database Jan 1992-Dec Jan 1992-Dec 20012001

CABGCABG75.2%75.2%

AVR

AVR+CABG

MVR

MVR+CABG

AVR+MVR

MV Repair

MV Repair+CABG

Other

4.18%

4.26%

2.01%

1.37%0.86%0.92%

10.7%


[ http://www.ktcs.or.kr/ ]

대한흉부외과학회 대한흉부외과학회 Database Database 2001-2001-20052005

2527 25412409 2420 2347

0

500

1000

1500

2000

2500

3000

2001 2002 2003 2004 2005

ValveCABGCABG+Valve

1968

1700

21762340

2055

123 147 145 185 213


CABG with Aortic Valve diseaseCABG with Aortic Valve disease


AV Replace

AV Replace+CABG

Procedure year

Pe

rce

nt

1994 1995 1996 1997 1998 1999 2000 2001

Combinded Procedures. In: Surgery of Coronary artery disease, Wheatley DJ. London: Arnold 2003, 326-33.

0

10

8

6

4

2

Operative Mortality for AVR Operative Mortality for AVR with with or or

withoutwithout CABG CABG –STS Database-–STS Database-


Lytle BW. JTCS 1988;95:402-14

Long-term Survival after AVR with Long-term Survival after AVR with CABGCABG

Major cardiac event: reoperation, permanent neurologic event, MI, bleeding, endocarditis, hospitalization for CHF, NYHA III/IV Sx, death


Jones EL. ATS 1994;58:378-85

No CAD(N=1396)Mean Age 56yrs

CAD(N=883)Mean Age 67yrs

Hosp. Mortality

3.4%

7.9%

39%

60%

p<0.0001

Time (Yrs)

Su

rviv

al

0 5 10 15 20

0.0

0.2

0.4

0.6

0.8

1.0

Survival after AVR with/without Survival after AVR with/without CABGCABG


Stewart BF. JACC 1997;29:630-4

VariableP

valueOdds Ratio

95% Confidence Limits

Age <0.001 2.18* 2.15,2.20

Male gender

<0.001 2.03 1.7,2.5

Lp(a) <0.001 1.23† 1.14,1.32

Height(cm)

0.001 0.84‡ 0.75,0.93

HBP 0.002 1.23 1.1,1.4

Smoking 0.006 1.35 1.1,1.7

LDLc(mg/dl)

0.008 1.12† 1.03,1.23*±75th vs 25th percentile. †±10-year increase. ‡±10unit increase. LDLc=low density lipoprotein cholesterol; Lp(a)=lipoprotein(a)

Clinical Factors associated with Clinical Factors associated with Calcific Calcific

Aortic Valve diseaseAortic Valve disease


Pohle K. Circulation 2001;104:1927-32

AV Calcification associated with AV Calcification associated with Coronary AtherosclerosisCoronary Atherosclerosis


Atherosclerotic Changes in Aortic Atherosclerotic Changes in Aortic Valves of Valves of Hypercholesterolemic RabbitsHypercholesterolemic Rabbits

Aortic Valve-Cholesterol diet

Aortic Valve-Cholesterol diet

Aorta-Cholesterol diet

Aorta-Normal diet


Fiore AC. ATS 1996;61:1693-8

CABG then AVR

CABG with AVR

Mild AS >1.0cm2

26±10mmHg1.05±0.2cm2

61.3±26mmHg0.69±0.12cm2

8.9yr

CABG then AVR CABG/AVR

53.2±24mmHg0.73±0.21cm2

Management of Asx Mild AS during Management of Asx Mild AS during

CABGCABG

p = NS

PERCENT

YEARS

100

80

60

40

20

0

0 21 3 4 5 6 7 8 9 10


Hochrein J. Am Heart J 1999;138:791-7

24.3%

3%

Mean AS gradient CABG: 25.9±11.2 (14-66) mmHg AVR/CABG: 52.5±18.9 (14-126) mmHg

Freedom from AVRFreedom from AVR (CABG)(CABG) vs AV Reopvs AV Reop (AVR/CABG)(AVR/CABG)

in Mild to Moderate AV Diseasein Mild to Moderate AV Disease

P=0.0024

CABG

AVR/CABG


Mild AS

: Mean PG< 30mmHg, and/or Valve area >1.5cm2

Moderate AS: Mean PG≥30mmHg and ≤40mmHg, and/or

Valve area >1.0 and ≤ 1.5cm2

Pereira JJ. Am J Med 2005;118:735-42

Survival after Mild/Moderate AVR Survival after Mild/Moderate AVR with CABGwith CABG

AVR-CABG

AVR-CABG

CABG

CABG


Tom JW. ATS 1998;65:1215-9

1 3 75 92 64 80 yrs

Progression of Mild AS in CABG Progression of Mild AS in CABG PatientsPatients

VariableEvent-FreeSurvivors

Progressionto Severe AS

P value

Age(yr) 61.1±9.5 60.0±9.6 NS

AS gradient (mmHg)

9.6±7.1 20.7±9.9 0.0005

Calcium score

0.8±0.7 1.3±0.7 0.06

Mobility score 0.9±0.8 1.0±0.9 NS


Rosenhek, R. Eur Heart J 2004 25:199-205

No CAD (1,3,5yr) : 98±1%, 86±3%, 74±4%

CAD (1,3,5yr) : 94±3%, 63±7%, 40±8% (p=0.0002)

Predictors of OutcomePredictors of Outcome- Calcification, AV velocity, CAD -- Calcification, AV velocity, CAD -


Smith IV WT. J Am Coll Cardiol 2004;44:1241-7

1995-2000, 1,344,100 CABG, CABG/AVR, AVR after CABG

in STS National Database

0

10

20

30

40

50

60

70

Immediate 1yr 5yr 10yr 15yr

CABG CABG/AVR

0

20

40

60

80

100

Immediate 1yr 5yr 10yr 15yr

CABG CABG/AVR

Death Event Free

65-yr-old, Peak AV Gradient 65-yr-old, Peak AV Gradient 30mmHg, Progression of AS of 30mmHg, Progression of AS of

5mmHg/Yr5mmHg/Yr


Smith IV WT. J Am Coll Cardiol 2004;44:1241-7

CABG/AVR preferred

preferredCABG

1995-2000, 1,344,100 CABG, CABG/AVR, AVR after CABG

in STS National Database

Rate of AS progression: 5mmHg/year

Should CABG undergo Concomitant Should CABG undergo Concomitant

AVRAVRin Mild or Moderate AS ?in Mild or Moderate AS ?

- A Decision Analysis Approach to the Surgical Dilemma -- A Decision Analysis Approach to the Surgical Dilemma -

Age at time of CABG


10.4. AVR in Patients Undergoing CABG

• Class I AVR is indicated in patients undergoing CABG who have severe AS who meet the criteria

for valve replacement (see Section 3.1.7). (Level of Evidence: C)

Circulation 2006;114;84-231

• Class IIa AVR is reasonable in patients undergoing CABG who have moderate AS (mean gradient 30 to

50 mmHg or Doppler velocity 3 to 4 m/sec). (Level of Evidence: B)

• Class IIb AVR may be considered in patients undergoing CABG who have mild AS (mean gradient less

than 30 mm Hg or Doppler velocity less than 3 m/sec) when there is evidence, such as moderate severe valve calcification, that progression may be rapid. (Level of Evidence: C)

ACC/AHA 2006 Guidelines for the Management

of Patient With VHD


Bauer EP. EJCTS 1996;10:248-52

Variable IMA(n=68)

SVG(n=120)

P value

Non-survivors 4(6%) 6(5%) NS

Mechanical ventilation(hours)

30±4.8 21±3.5 NS

Catecholamine support 34(50%) 67(56%) NS

CK-MB(highest value) 43±3.0 42±4.2 NS

Transfusion 30(44%) 62(52%) NS

ICU stay(days) 4.4±0.7 4.0±0.3 NS

Rethoracotomy 1(1.5%) 2(1.6%) NS

Sternal wound infection 0 1(0.8%) NS

Ustable sternum 1(1%) 0 NS

Is the Use of IMA a Predictor for Early Is the Use of IMA a Predictor for Early

Complications?Complications?


Gall S. ATS 2000;69:524-30

LAD-IMA vs LAD-SVG

p=0.0017

No LAD

LAD-SVG

LAD-IMA

Efficacy of IMA in AVR with Efficacy of IMA in AVR with

CABGCABG


Observed Survival Adjusted Survival

Karthik S. ATS 2005;80:163-9

Mean F/U Period: average 3.7yrs

Effect of LIMA-LAD in AVR with Effect of LIMA-LAD in AVR with

CABGCABG


Kobayashi KJ. ATS 2007;83:969-78

One graft

Two graft

Multiple graft

2000-2004

378 AVR-CABG at Johns Hopkins

Impact of Multiple Grafts in AVR with Impact of Multiple Grafts in AVR with

CABGCABG

P=0.91

Mean F/U Period: average 2.2±1.7yrs


Lytle BW. JTCS 1988;95:402-14

PERCENT100

60

40

20

80

BIOPROSTHESIS, n=218

MECHANICAL, n=253

Long-term Survival according to Valve Long-term Survival according to Valve Type in AVR & CABGType in AVR & CABG


Puvimanasinghe JPA. EJCTS 2003;23:688-95

AVR without CABG AVR with CABG

LE: Life Expectancy

EFLE: Event-Free Life Expectancy

11.6yr

11.2yr8.9yr

8.2yr

9.9yr

10.2yr

7.4yr

8.1yr

59-60yr 58-

59yr

Comparison of Life Expectancy & Comparison of Life Expectancy &

Event Free Life ExpectancyEvent Free Life Expectancy


Puvimanasinghe JPA. EJCTS 2003;23:688-95

• AVR without CABG: 63yrs

• AVR with CABG: 62yrs

Lifetime Risk of SVD with Lifetime Risk of SVD with

Bioprosthesis, Bioprosthesis,

Hemorrhage with Mechanical ValveHemorrhage with Mechanical Valve


LeBoutillier III M. Valvular and IHD. In: Cohn LH. Cardiac Surgery in the Adult. 2nd ED. New York: McGraw-Hill Co. 2003;1061

Operative Sequences for AVR & Operative Sequences for AVR &

CABGCABG

Distal anastomosis at first


CABG with Mitral Valve diseaseCABG with Mitral Valve diseaseCABG with Mitral Valve diseaseCABG with Mitral Valve disease


Combinded Procedures. In: Surgery of Coronary artery disease, Wheatley DJ. London: Arnold 2003, 326-33

Pe

rce

nt

20

15

10

5

Procedure year

1994 1995 1996 1997 1998 1999 2000 2001

MV Replace

MV Replace+CABG

0

Operative Mortality for MVR Operative Mortality for MVR with/without CABGwith/without CABG –STS Database-–STS Database-

Operative Mortality for MVR Operative Mortality for MVR with/without CABGwith/without CABG –STS Database-–STS Database-


Lytle BW. Circulation 1985;71:1179-90

Long-term Survival after MVR & Long-term Survival after MVR &

CABGCABG


Czer LSC. Circulation 1984;70 (suppl I):I-198-I-207

1969-1982, 419 MVR patients No CAD: 216

CAD with CABG: 179

CAD without CABG: 24

Unmatched Cohort Matched Cohort

NO CAD

CAD and CABG

CAD, No CABG

P=0.07

P<0.05

Survival after MVR with or without Survival after MVR with or without

CADCAD

No CAD vs CABG P=0.07

CABG vs CAD, No CABG P<0.05



NO CAD

CAD and CABG

CAD, No CABG

P<0.05

Survival after MVRSurvival after MVR & Incidental CAD & Incidental CAD (Rheumatic)(Rheumatic)


Jones EL. ATS 1994;58:378-85

Hosp. Mortality5.6%

14.2% No CAD(N=934)Mean Age 54yrs

CAD(N=340)Mean Age 64yrs

p<0.0001

Time (Yrs)

Su

rviv

al

0.0

0.2

0.4

0.6

0.8

1.0

0 102 4 6 8

Survival after MVR with/without Survival after MVR with/without

CADCAD


Lytle BW. Circulation 1985;71:1179-90

P=0.02

Survival of MVR with CABGSurvival of MVR with CABG based on Etiology of MVDbased on Etiology of MVD


Rheumatic

P<0.01

Ischemic

Other

Survival according to Survival according to

EtiologyEtiology



Seipelt RG. EJCTS 2001;20:270-5

Hospital Mortality Ischemic: 19.5% Rheumatic 7.9% Degenerative: 2.4%

P=NS

Jan 1984- Dec 1997262 MVR with CABG

Survival Rate

Degenerative MVDIschemic MVD

Rheumatic MVD

Survival of Combined MVD & Survival of Combined MVD &

CABGCABG based on Etiology of MVDbased on Etiology of MVD

1.0

0.8

0.6

0.4

0.2

0

0 2 4 6 8 10Years


Gillinov AM. ATS 2005;80:811-9

Unadjusted Survival Adjusted Survival

Ischemic MR Degenerative MR with CAD

LV dysfunction → MR MR ± LV dysfunction

p<0.0001 p>0.9

One disease Two disease

Degenerative MR with CAD vs Ischemic MR


Gillinov AM. ATS 2005;80:811-9

Ischemic MR

Homogeneous Survival Curve

Degenerative MR

Inhomogeneous Survival Curve

Severity of CAD and LV dysfunction

impact on Survival

Degenerative MR with CAD vs Ischemic MR


Univariate

p value

Multivariate

p value

Age > 72yrs 0.0001 < 0.0001

EF < 35% < 0.0001 0.0039

Replacement 0.037 0.019

3-vessel CAD 0.0001 0.0086

Dismissal MR > 2 0.019 0.042

NYHA III/IV 0.0002 0.072

Ischemic 0.0036 0.21

Dahlberg PS. ATS 2003;76:1539-48

Late Outcome of MV Surgery & Late Outcome of MV Surgery &

CABGCABG


Overall Survival for Repair and Replace

for association of CABG

Akins CW. ATS 1994;58:668-76


Thourani VH. Circulation 2003;108:298-304

No Survival Benefit in Mitral Repair and CABG

Matched Case-Control Study


Enrinquez-Sarano M. Circulation 1995;91:1022-8

Overall Survival for Repair and Replace

for association of CABG

With CABG Without CABG

RepairReplacement

P=0.0008P=0.0002

Years

Ove

rall

su

rviv

al (

%)

74±8%

34±8%

73±7%

61±5%

• Jan 1980-Dec 1989, 409 Organic MR (except Ischemic MR)• Repair 195, Replacement 214


Enriquez-Sarano M. Circulation 2003;108:253-6

Survival for Repair and Replacement

for concomitant CABG

P<0.01

•1980- 1995, 1344 Pure MR • Repair 897, Replacement 447


Gillinov AM. JTCS 2003;125:1350-62

Repair vs Replacement for Repair vs Replacement for

Degenerative Degenerative

MVD with IHDMVD with IHD

• 1973- 1999, 679 Degenerative MR with CABG• Repair 447, Replacement 232


Gillinov AM. JTCS 2003;125:1350-62

Survival benefit of

Repair

Repair vs Replacement for Degenerative MVD with IHD


Operative Operative

SequencesSequencesfor MVR & CABGfor MVR & CABG

LeBoutillier III M. Valvular and IHD. In: Cohn LH. Cardiac Surgery in the Adult. 2nd ED. New York: McGraw-Hill Co. 2003;1066


Experiences in St. Paul’s Experiences in St. Paul’s

HospitalHospital

AV Surgery MV SurgeryIncidence 9/369 (2.4%) 12/369 (3.3%)

Sex(M:F) 5:4 6:6

Age 67.2±6.9 63.6±7.9

Etiology

Degenerative 7 1

Rheumatic 1 3

Congenital 1

Ischemic (Functional) 7

Ischemic (PM rupture) 1

Number of bypass graft 1.4±0.7 2.2±0.8

Graft

LIMA 8(88.9%) 9(75%)

SVG 5


Experiences in St. Paul’s Experiences in St. Paul’s

HospitalHospital

AV Surgery MV SurgeryCPB time (min) 229.0±65.9 283.1±93.9

ACC time (min) 182.6±50.0 198.9±45.7

Complications

Mediastinitis 1

Sudden cardiac arrest 1

Pneumonia 1

ARF 3

Hepatic failure 1

Bleeding 2

Low cardiac output 3

Operative mortality 1/9 (11.1%) 2/12 (16.7%)


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DEPARTMENT OF THORACIC & CARDIOVASCULAR SURGERY ST. PAUL ’ S HOSPITAL