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Should coronary arteriography be performed routinely before valve replacement?
Should Coronary Arteriography Be Performed Routinely Before Valve Replacement?
LAWRENCE I. BONCHEK, RICHARQ. P. ANDERSON, JOSEF ROSCH, MD
MD* MD
The implication that coronary atherosclerosis is a common cause of complications and death after prosthetic heart valve replacement has resulted in the performance of routine preoperative coronary arteriography in many clinics. A review of 4 years’ experience with such studies at the University of Oregon Medical School Hospital indicates that patients with significant coronary obstruction in conjunction with valvular heart disease always had angina pectoris. None of the postoperative deaths or complications were due to demonstrable coronary artery disease without preexisting angina. It is likely that the increased cardiac work load imposed by valvular heart disease increases myocardial oxygen demands. Significant coronary atherosclerosis is therefore unlikely to remain asymptomatic. Coronary arteriography may be safely omitted before valve replacement in many patients with increased myocardial work who have no symptoms of ischemic heart disease, and who lack risk factors known to increase its incidence.
Portland, Oregon
Coronary artery disease has often been implicated as a cause of death or complications after prosthetic heart valve replacement.1 Since aortocoronary vein bypass grafts now provide a method for treating coronary artery disease in conjunction with valvular disease, it has been suggested that patients over 40 years of age undergoing heart valve replacement should routinely have preoperative coronary arteriography. 2m4Such studies have been electively performed in our clinic for 4 years, and during the past year and a half, they have been routine. Since coronary arteriographic studies incur mortality, morbidity and expense, we reviewed the experience with prosthetic valve replacement at the University of Oregon Medical School Hospital in the past 4 years, to determine whether such studies should be routinely performed. If patients without coronary artery disease could be identified clinically without arteriography, studies could then be selectively performed only in patients whose management was likely to be influenced by the arteriographic findings. Methods
From the University of Oregon Medical School Hospital, Portland, Ore. This study was supported in part by National Heart and institute Project Grant Lung Program HL 06336. Manuscript received August 14. 1972; accepted September 29, 1972. *Dr. Bonchek is the recipient of Career Development Award HL 70035. Address for reprints: Lawrence I. Bonchek, MD, University of Oregon Medical School, 3181 SW. Sam Jackson Park Rd., Portland, Ore. 97201.
462
April 1973
The American
Journal
and Materials
From January 1968 until December 1971, 178 patients over age 40 years had prosthetic replacement of one or more heart valves. One hundred patients had preoperative coronary arteriography and constitute Group A. There were 50 men with a mean age of 56.6 years, and 50 women with a mean age of 55.1 years. Fourteen patients were in their fifth decade, 44 in their sixth decade, and 42 in their seventh decade. Forty-seven patients had aortic valve replacement, 30 had mitral valve replacement and 23 had multiple valve replacement (17 mitral and aortic, 4 mitral and tricuspid and 2 triple valve replacements). During the same period, 78 patients had prosthetic valve replacement without preoperative coronary arteriography (Group B). Most of these patients had surgery during the early portion of the experience, before coronary arteriography was routinely performed. In the others, it was omitted because their precarious clinical condition re-
of CARDIOLOGY
Volume
31
CORONARY
TABLE
ARTERIOGRAMS
BEFORE
VALVE
REPLACEMENT-BONCHEK
ET AL.
I
Group A. Incidence
and Severity of Angina According
to Type of Valvular
Disease Angina
No Angina: All Grades
Grade 0 no.
Valvular Disease
no.
%
Grade
I
Grade
(no.)
%
Grade III
II
(no.)
Total no.
(no.)
Mitral
24
80
6
20
5
1
0
30
Aortic
24
51
23
49
11
10
2
47
Multiple
17
74
6
26
5
1
0
23
Total
65
21
12
2
100
35
characteristics was not considered angina. Angina was graded in severity as follows: grade 0, no angina; grade I, angina only with severe exertion; grade II, angina with ordinary activity, emotional stress or exposure to cold; grade III, nocturnal angina or angina at rest. All patients were classified according to New York Heart Association functional class II, III or IV as a result of their valvular heart disease alone. The records of datients in Group A were analyzed to determine’ if the findings of coronary arteriography significantly altered the operative or postoperative management of each case (that is, by resulting in aortocoronary vein bypass graft), or were accompanied by operative or postoperative complications such as myocardial infarction, arrhythmias or low cardiac output. Since patients in Group B did not have preoperative coronary arteriography, objective information about coronary arterial anatomy was available only in those who died postoperatively and whose coronary arteries were dissected at necropsy. Preoperative symptoms of angina were therefore not graded in severity since they could not be correlated with coronary anatomy in a sufficient number of cases. Rather, all deaths and complications were attributed to coronary artery disease if no other definite cause was apparent and the coronary arteries were not examined at necropsy. In such cases, preoperative coronary arteriography might therefore have altered patient management.
quired urgent surgery, or because their hemodynamic evaluation was performed elsewhere before admission, and an additional intervention was deemed unwise. In this group, there were 51 women with a mean age of 51.5 years, and 27 men with a mean age of 51.4 years. Thirtythree patients were in their fifth decade, 33 in their sixth decade, 11 in their seventh decade and 1 in the eighth decade. Twenty-five patients had aortic valve replacement, 33 had mitral valve replacement and 20 had multiple valve replacement (9 mitral and aortic, 9 mitral and tricuspid and 2 triple valve replacements). With rare exception, all patients had complete hemodynamic studies including left and right heart catheterization and left ventriculography. Coronary arteriograms were obtained with the Judkins technique, usually by percutaneous puncture of the femoral artery.5 Both cineangiograms and direct radiograms were ordinarily obtained. Interpretations of the arteriograms were carried out without knowledge of the patient’s clinical management. Coronary arteries were considered normal when there was no angiographically demonstrable disease. Mild coronary atherosclerosis was defined as demonstrable atherosclerotic disease with less than 60 percent narrowing of 1 major coronary artery. Significant coronary atherosclerosis was defined as greater than 60 percent obstruction of 1 or more major coronary arteries. Clinical data were analyzed as to the incidence of preoperative angina, myocardial infarction, risk factors such as hypertension or diabetes, electrocardiographic abnormalities and long-term functional results. Angina was defined as substernal or left precordial chest pain, with or without radiation to the shoulders, hand or arm, that was precipitated by exercise, emotional stress or exposure to cold and was relieved by rest or nitroglycerin, or both. The pain need not have been “squeezing” or “constricting” in nature, but atypical pain without any of the other
TABLE
Results Clinical features: In Group A, 65 patients (65 percent) had no angina, 21 had grade I angina, 12 had grade II angina, and 2 had grade III angina. The incidence and severity of angina are classified according to the type of valve disease in Table I. Four patients had systemic hypertension, 6 had diabetes,
II
Group A. Incidence
and Severity
of Coronary
Artery
Disease*
According
to Presence
No Angina Valvular Disease
Normal*
Mitral Aortic Multiple
20 19 14
Tota I
53
* Angiographic
grading
of coronary
Disease
Angina
Mild*
artery
of Angina and Type of Valvular
Severe*
Normal*
Mild*
Severe*
Total
4 5 3
0 0 0
4 14 5
2 4 0
0 5 1
30 47 23
12
0
23
6
6
100
disease
(see
text).
April 1973
The American Journal of CARDIOLOGY
Volume 31
463
CORONARY
TABLE
ARTERIOGRAMS
BEFORE VALVE
REPLACEMENT-SONCHEK
III
Group A. Sex Distribution
of Coronary
Artery
Disease and Type of Valvular
Mitral Coronary Artery Disease Normal Mild Severe Total
April 1973
Disease
Aortic
Multiple
Total ____-Female
Male
Female
Male
Female
Male
Female
Male
6 4 0
18 2 0
22 7 4
11 2 1
6 0 1
13 3 0
34 11 5
42 7 1
10
20
33
14
7
16
50
50
and 2 had electrocardiographic evidence of prior infarction. In Group B, 55 patients (71 percent) had no angina and 23 (29 percent) had angina. Although 15 percent of patients with mitral or multiple valve disease had angina (5 of 33 and 3 of 20, respectively), 60 percent (15 of 25) with aortic valve disease alone had angina. Coronary anatomy: In Group A, 76 patients had angiographically normal coronary arteries, 18 had mild coronary disease, and 6 had significant coronary disease. The incidence and severity of coronary artery disease is compared to the presence of angina and to the type of valve disease in Table II. None of the 65 patients without angina had significant coronary obstruction. Of the 35 patients with angina, 6 had significant coronary disease, 6 had mild disease and 23 had normal coronary arteries. Of these 23 patients, 6 had mitral valve disease with right ventricular hypertension (systolic pressure >40 mm Hg at rest) as the presumed cause of their angina. The remaining 17 had aortic valve disease alone or in conjunction with mitral valve disease. Four of the 6 patients with angina and significant coronary obstruction had combined vein graft and valve replacement. The remaining 2 patients were seen early’in the series, and aortocoronary vein bypass was not considered essential to a good functional result in these sedentary patients. Sex distribution: For Group A, the distribution of coronary artery disease and the type of valve disease according to sex is summarized in Table III. Twothirds of the patients with mitral or multiple valve disease were men. Five of the six patients with severe coronary artery disease were men, and 11 of 18 patients with mild coronary artery disease were men. In Group B, 88 percent of the patients (29 of 33) having mitral valve replacement and 77 percent (14 of 20) having multiple valve replacement were women. Only 32 percent of patients (8 of 25) having aortic valve replacement were women. Operative mortality and morbidity: In Group A there were 9 hospital deaths (9 percent). Seven of the 9 deaths occurred in patients with normal coronary arteries and resulted from operative hemorrhage in 1, intractable arrhythmias in 2 and myocardial failure with reduced cardiac output in 4. The
464
ET AL.*
The American Journal of CARDIOLOGY
eighth patient had mild coronary disease demonstrated angiographically and at necropsy, and no preoperative angina. He died after aortic valve replacement with a myocardial infarction that presumably resulted from myocardial ischemia during valve insertion. The ninth patient had severe preoperative angina and died of reduced cardiac output after thrombosis of a vein graft performed with double valve replacement. There were no other postoperative complications attributable to coronary artery disease. In Group B there were 8 operative deaths (10.3 percent). Three of these patients had no preoperative angina, and all 3 died of myocardial failure with reduced cardiac output. In 2 of the patients the coronary arteries were entirely normal at necropsy, and the third had mild, nonobstructive disease. The remaining 5 patients had angina preoperatively. There were no immediate postoperative complications such as persistent ventricular arrhythmias, myocardial infarction or reduced cardiac output that could have been attributed to coronary artery disease in the 50 surviving patients who did not have preoperative angina. Late mortality and morbidity: In Group A, there were 7 late deaths. Three patients had normal coronary arteries and no angina, and died from a cerebrovascular accident, a dissecting aortic aneurysm and an impacted poppet, respectively. The remaining 4 patients had angina preoperatively. One patient with grade I angina and angiographically normal coronary arteries had electrocardiographic evidence of a myocardial infarction after aortic valve replacement. This was presumably due to a coronary embolus that was calcific or thrombotic. None of the deaths or complications, early or late, were due to demonstrable coronary artery disease without preexisting angina. All surviving patients are free of aqgina, including the 2 with coronary obstruction in whom vein bypass graft was avoided. In Group B, there were 9 late deaths. Five patients had no preoperative angina. One died of pacemaker failure after triple valve replacement, and 1 died of arrhythmias due to digitalis toxicity. The third was doing well postoperatively and died suddenly at home, presumably of an arrhythmia. Two patients died with residual left ventricular dysfunction and
Volume 31
CORONARY
ARTERIOGRAMS
congestive heart failure that was not alleviated by double valve replacement. Coronary disease was considered unlikely, and coronary arteriograms were not obtained despite ample opportunity to do so after failure of the condition to improve had become evident. It is doubtful that coronary arteriography would have influenced the management of these patients. The remaining 4 patients had angina preoperatively. Complications of arteriography: One patient had a myocardial infarction documented by electrocardiographic changes and serum enzyme elevations. Persistent chest pain followed injection into the right coronary artery and was probably due to injection of a fibrin clot, since the coronary arteries were normal. The patient recovered, and later had uneventful mitral valve replacement. There were no serious arrhythmias, no arterial injuries and no deaths. Discussion The detection of coronary atherosclerosis in patients with valvular heart disease is no longer of prognostic importance alone, since direct revascularization of the heart by means of aortocoronary bypass grafts may be combined with valvular heart surgery.4 Preoperative coronary arteriography is now routinely performed in many centers.2Ta A review of the findings in 100 patients who had such studies during the past 4 years, and in 78 patients who had valve replacement without such studies, indicates that coronary atherosclerosis significant enough to alter patient management or to require revascularization was apparent clinically. All patients who had critically obstructing coronary arterial lesions had angina pectoris. Thus, if coronary arteriography had been restricted to patients with preoperative angina, there would have been no change in the surgical management of any patient.
Significant coronary arterial obstruction has been shown to correlate closely with the clinical diagnosis of angina pectoris.6 Nonetheless, significant coronary atherosclerosis is occasionally found in asymptomatic persons, and it is pertinent to consider why this was not true of the patients reported here. Our patients with angina pectoris and normal coronary arteries had increased left ventricular work as a result of aortic valve disease, or increased left and right ventricular work (systolic pressure greater than 40 mm Hg) as a result of mitral valve disease. Both of these conditions are known to cause angina in the absence of coronary artery disease.? It is likely that the increased cardiac work load imposed by chronic valvular disease causes increased myocardial oxygen demands. As a result, significant coronary atherosclerosis is unlikely to remain asymptomatic. All survivors in this study were relieved of angina postoperatively, although only 3 in Group A had aortocoronary vein bypass grafts. This symptomatic improvement indicates the adequacy of their coronary blood flow when abnormal cardiac hemodynamics were corrected.
BEFORE
VALVE
REPLACEMENT-BONCHEK
ET AL.
There were no patients with isolated mitral stenosis in this review, since they do not ordinarily require valve replacement. Because patients with pure mitral stenosis and without pulmonary hypertension have no increase in ventricular work-particularly with restricted activity-they may be more likely to have asymptomatic coronary arterial obstruction than other patients with valvular heart disease. Risk factors such as diabetes, hypertension and a family history of atherosclerotic heart disease were too infrequent in our patients to permit statistically significant conclusions, but their proved association with atherosclerosis is such that their presence in an individual patient should cause concern. Although asymptomatic coronary arterial obstruction was not seen in our 178 patients with valvular heart disease, it will inevitably occur. Such patients are more likely to be found amongst those with known risk factors, and it is in these patients that the indications for preoperative arteriography should be the most liberal. The incidence of coronary atherosclerosis in these 178 patients may not be the same in other populations of patients undergoing valve replacement, since the incidence of coronary atherosclerosis is affected by age and sex. A group of patients who are older, or have a higher proportion of men, might have more coronary atherosclerosis than the group reported here. Nonetheless, the relation between angiographic evidence of coronary atherosclerosis and the presence of angina pectoris should be maintained by the mechanisms discussed. Recommendations that coronary arteriography be performed routinely in patients undergoing valve replacement have usually been based upon autopsy findings in patients who died after valve replacement.ls.9 Such findings were believed to indicate that coronary atherosclerosis is a prominent cause of morbidity and mortality after valvular heart surgery. In those studies coronary artery disease was often inferred when myocardial fibrosis was found, yet the two entities are not necessarily synonymous, since fibrosis is often associated with congenital cardiac defects, rheumatic carditis and various cardiopathies.lO (Myocardial fibrosis is found more commonly with mitral valve disease than with aortic valve disease,” probably because mitral disease is more often rheumatic.l) Further, autopsy findings in other studies were not correlated with preoperative symptoms of ischemic heart disease or with the severity of coronary artery disease among survivors of operation. Finally, such recommendations do not consider the risks, expense and discomfort of .routine arteriography. Recently reported experience at the University of Oregon Medical School indicates an incidence of significant cardiac complications (e.g., arrhythmias or infarction) of less than 1 percent, and significant vascular complications (e.g., femoral thrombosis) of 1 percent. Death is much rarer.12 However, such risks vary widely in different clinics in relation to the number of procedures performed.
April 1973
The American Journal of CARDIOLOGY
Volume 31
465
CORONARY
ARTERIOGRAMS
BEFORE VALVE
REPLACEMENT-BONCHEK
Conclusions It may be concluded from our experience that patients with valvular heart disease and no angina are unlikely to have significant coronary obstruction. Coronary arteriography before valve replacement should be performed if the value of the information to be gained outweighs the risks undertaken. At the University of Oregon Medical School, in conjunction with the program of research in valvular heart disease, coronary arteriography may provide valuable insight into operative risk, long-term prognosis and
ET AL.
the functional results of valve replacement. In comparison to the low risk of coronary arteriography in this clinic such information is of value, and we will continue to perform arteriography routinely in patients over 40 years. In clinics where the morbidity and mortality of arteriography are higher, or the information to be gained is less relevant, coronary arteriography may be safely omitted before valve replacement in many patients with increased myocardial work who have no symptoms of ischemic heart disease, and who lack risk factors known to increase its incidence.
References 1. Peterson CR, Herr R, Crisera RV, et al: The failure of hemodynamic improvement after valve replacement surgery. Ann Intern Med 66:1-24, 1967 2. Coleman EH, Soloff LA: Incidence of significant coronary artery disease in rheumatic valvular heart disease. Amer J Cardiol 25:401-404, 1970 3. Lesage CH, Vogel JHK, Bloqnt SG: latrogenic coronary occlusive disease in patients with prosthetic heart valves. Amer J Cardiol 25:123-129. 1970 4. Flemma RJ, Johnson WD, Lepley D, et al: Simultaneous valve replacement and aortocoronary saphenous vein bypass. Ann Thorac Surg 12:163-170, 1971 5. Judklns MP: Percutaneous transfemoral selective coronary arteriography. Radio1 Clin N Amer 6:467-492. 1968 6. Proudfif WL, Shirey EK, Sones FM Jr: Selective tine coronary arteriography: correlation with clinical findings in 1000 patients. Circulation 33:901-910. 1966
466
April 1973
The American
Journal of CARDIOLOGY
7. Hurst JW, Logue RB: The Heart, Arteries, and Veins, second edition. New York, McGraw-Hill, 1970, p 954 8. Roberts WC, Morrow AG: Late postoperative pathological findings after cardiac valve replacement. Circulation: suppl 1: 35 and 36:48-62, 1967 9. Hodam R, Starr A, Raible D, et al: Totally cloth covered prosthesis: a review of two years’ clinical experience. Circulation: suppl 2: 41 and 42:33-38, 1970 10. Gould SE: Pathology of the Heart and Blood Vessels. Springfield, Ill, Charles C Thomas, 1968, p 240-261, 479526 Il. Flemming HA, Wood P: The myocardial factor in mitral valve disease. Brit Heart J 21 :117-l 22, 1959 12. Green GS, McKinnon CM, Rosch J, et at: Complications of selective percutaneous transfemoral coronary arteriography and their prevention: a review of 445 consecutive examinations. Circulation 65:552-557, 1972
Volume 31
LAWRENCE I. BONCHEK, RICHARQ. P. ANDERSON, JOSEF ROSCH, MD
MD* MD
The implication that coronary atherosclerosis is a common cause of complications and death after prosthetic heart valve replacement has resulted in the performance of routine preoperative coronary arteriography in many clinics. A review of 4 years’ experience with such studies at the University of Oregon Medical School Hospital indicates that patients with significant coronary obstruction in conjunction with valvular heart disease always had angina pectoris. None of the postoperative deaths or complications were due to demonstrable coronary artery disease without preexisting angina. It is likely that the increased cardiac work load imposed by valvular heart disease increases myocardial oxygen demands. Significant coronary atherosclerosis is therefore unlikely to remain asymptomatic. Coronary arteriography may be safely omitted before valve replacement in many patients with increased myocardial work who have no symptoms of ischemic heart disease, and who lack risk factors known to increase its incidence.
Portland, Oregon
Coronary artery disease has often been implicated as a cause of death or complications after prosthetic heart valve replacement.1 Since aortocoronary vein bypass grafts now provide a method for treating coronary artery disease in conjunction with valvular disease, it has been suggested that patients over 40 years of age undergoing heart valve replacement should routinely have preoperative coronary arteriography. 2m4Such studies have been electively performed in our clinic for 4 years, and during the past year and a half, they have been routine. Since coronary arteriographic studies incur mortality, morbidity and expense, we reviewed the experience with prosthetic valve replacement at the University of Oregon Medical School Hospital in the past 4 years, to determine whether such studies should be routinely performed. If patients without coronary artery disease could be identified clinically without arteriography, studies could then be selectively performed only in patients whose management was likely to be influenced by the arteriographic findings. Methods
From the University of Oregon Medical School Hospital, Portland, Ore. This study was supported in part by National Heart and institute Project Grant Lung Program HL 06336. Manuscript received August 14. 1972; accepted September 29, 1972. *Dr. Bonchek is the recipient of Career Development Award HL 70035. Address for reprints: Lawrence I. Bonchek, MD, University of Oregon Medical School, 3181 SW. Sam Jackson Park Rd., Portland, Ore. 97201.
462
April 1973
The American
Journal
and Materials
From January 1968 until December 1971, 178 patients over age 40 years had prosthetic replacement of one or more heart valves. One hundred patients had preoperative coronary arteriography and constitute Group A. There were 50 men with a mean age of 56.6 years, and 50 women with a mean age of 55.1 years. Fourteen patients were in their fifth decade, 44 in their sixth decade, and 42 in their seventh decade. Forty-seven patients had aortic valve replacement, 30 had mitral valve replacement and 23 had multiple valve replacement (17 mitral and aortic, 4 mitral and tricuspid and 2 triple valve replacements). During the same period, 78 patients had prosthetic valve replacement without preoperative coronary arteriography (Group B). Most of these patients had surgery during the early portion of the experience, before coronary arteriography was routinely performed. In the others, it was omitted because their precarious clinical condition re-
of CARDIOLOGY
Volume
31
CORONARY
TABLE
ARTERIOGRAMS
BEFORE
VALVE
REPLACEMENT-BONCHEK
ET AL.
I
Group A. Incidence
and Severity of Angina According
to Type of Valvular
Disease Angina
No Angina: All Grades
Grade 0 no.
Valvular Disease
no.
%
Grade
I
Grade
(no.)
%
Grade III
II
(no.)
Total no.
(no.)
Mitral
24
80
6
20
5
1
0
30
Aortic
24
51
23
49
11
10
2
47
Multiple
17
74
6
26
5
1
0
23
Total
65
21
12
2
100
35
characteristics was not considered angina. Angina was graded in severity as follows: grade 0, no angina; grade I, angina only with severe exertion; grade II, angina with ordinary activity, emotional stress or exposure to cold; grade III, nocturnal angina or angina at rest. All patients were classified according to New York Heart Association functional class II, III or IV as a result of their valvular heart disease alone. The records of datients in Group A were analyzed to determine’ if the findings of coronary arteriography significantly altered the operative or postoperative management of each case (that is, by resulting in aortocoronary vein bypass graft), or were accompanied by operative or postoperative complications such as myocardial infarction, arrhythmias or low cardiac output. Since patients in Group B did not have preoperative coronary arteriography, objective information about coronary arterial anatomy was available only in those who died postoperatively and whose coronary arteries were dissected at necropsy. Preoperative symptoms of angina were therefore not graded in severity since they could not be correlated with coronary anatomy in a sufficient number of cases. Rather, all deaths and complications were attributed to coronary artery disease if no other definite cause was apparent and the coronary arteries were not examined at necropsy. In such cases, preoperative coronary arteriography might therefore have altered patient management.
quired urgent surgery, or because their hemodynamic evaluation was performed elsewhere before admission, and an additional intervention was deemed unwise. In this group, there were 51 women with a mean age of 51.5 years, and 27 men with a mean age of 51.4 years. Thirtythree patients were in their fifth decade, 33 in their sixth decade, 11 in their seventh decade and 1 in the eighth decade. Twenty-five patients had aortic valve replacement, 33 had mitral valve replacement and 20 had multiple valve replacement (9 mitral and aortic, 9 mitral and tricuspid and 2 triple valve replacements). With rare exception, all patients had complete hemodynamic studies including left and right heart catheterization and left ventriculography. Coronary arteriograms were obtained with the Judkins technique, usually by percutaneous puncture of the femoral artery.5 Both cineangiograms and direct radiograms were ordinarily obtained. Interpretations of the arteriograms were carried out without knowledge of the patient’s clinical management. Coronary arteries were considered normal when there was no angiographically demonstrable disease. Mild coronary atherosclerosis was defined as demonstrable atherosclerotic disease with less than 60 percent narrowing of 1 major coronary artery. Significant coronary atherosclerosis was defined as greater than 60 percent obstruction of 1 or more major coronary arteries. Clinical data were analyzed as to the incidence of preoperative angina, myocardial infarction, risk factors such as hypertension or diabetes, electrocardiographic abnormalities and long-term functional results. Angina was defined as substernal or left precordial chest pain, with or without radiation to the shoulders, hand or arm, that was precipitated by exercise, emotional stress or exposure to cold and was relieved by rest or nitroglycerin, or both. The pain need not have been “squeezing” or “constricting” in nature, but atypical pain without any of the other
TABLE
Results Clinical features: In Group A, 65 patients (65 percent) had no angina, 21 had grade I angina, 12 had grade II angina, and 2 had grade III angina. The incidence and severity of angina are classified according to the type of valve disease in Table I. Four patients had systemic hypertension, 6 had diabetes,
II
Group A. Incidence
and Severity
of Coronary
Artery
Disease*
According
to Presence
No Angina Valvular Disease
Normal*
Mitral Aortic Multiple
20 19 14
Tota I
53
* Angiographic
grading
of coronary
Disease
Angina
Mild*
artery
of Angina and Type of Valvular
Severe*
Normal*
Mild*
Severe*
Total
4 5 3
0 0 0
4 14 5
2 4 0
0 5 1
30 47 23
12
0
23
6
6
100
disease
(see
text).
April 1973
The American Journal of CARDIOLOGY
Volume 31
463
CORONARY
TABLE
ARTERIOGRAMS
BEFORE VALVE
REPLACEMENT-SONCHEK
III
Group A. Sex Distribution
of Coronary
Artery
Disease and Type of Valvular
Mitral Coronary Artery Disease Normal Mild Severe Total
April 1973
Disease
Aortic
Multiple
Total ____-Female
Male
Female
Male
Female
Male
Female
Male
6 4 0
18 2 0
22 7 4
11 2 1
6 0 1
13 3 0
34 11 5
42 7 1
10
20
33
14
7
16
50
50
and 2 had electrocardiographic evidence of prior infarction. In Group B, 55 patients (71 percent) had no angina and 23 (29 percent) had angina. Although 15 percent of patients with mitral or multiple valve disease had angina (5 of 33 and 3 of 20, respectively), 60 percent (15 of 25) with aortic valve disease alone had angina. Coronary anatomy: In Group A, 76 patients had angiographically normal coronary arteries, 18 had mild coronary disease, and 6 had significant coronary disease. The incidence and severity of coronary artery disease is compared to the presence of angina and to the type of valve disease in Table II. None of the 65 patients without angina had significant coronary obstruction. Of the 35 patients with angina, 6 had significant coronary disease, 6 had mild disease and 23 had normal coronary arteries. Of these 23 patients, 6 had mitral valve disease with right ventricular hypertension (systolic pressure >40 mm Hg at rest) as the presumed cause of their angina. The remaining 17 had aortic valve disease alone or in conjunction with mitral valve disease. Four of the 6 patients with angina and significant coronary obstruction had combined vein graft and valve replacement. The remaining 2 patients were seen early’in the series, and aortocoronary vein bypass was not considered essential to a good functional result in these sedentary patients. Sex distribution: For Group A, the distribution of coronary artery disease and the type of valve disease according to sex is summarized in Table III. Twothirds of the patients with mitral or multiple valve disease were men. Five of the six patients with severe coronary artery disease were men, and 11 of 18 patients with mild coronary artery disease were men. In Group B, 88 percent of the patients (29 of 33) having mitral valve replacement and 77 percent (14 of 20) having multiple valve replacement were women. Only 32 percent of patients (8 of 25) having aortic valve replacement were women. Operative mortality and morbidity: In Group A there were 9 hospital deaths (9 percent). Seven of the 9 deaths occurred in patients with normal coronary arteries and resulted from operative hemorrhage in 1, intractable arrhythmias in 2 and myocardial failure with reduced cardiac output in 4. The
464
ET AL.*
The American Journal of CARDIOLOGY
eighth patient had mild coronary disease demonstrated angiographically and at necropsy, and no preoperative angina. He died after aortic valve replacement with a myocardial infarction that presumably resulted from myocardial ischemia during valve insertion. The ninth patient had severe preoperative angina and died of reduced cardiac output after thrombosis of a vein graft performed with double valve replacement. There were no other postoperative complications attributable to coronary artery disease. In Group B there were 8 operative deaths (10.3 percent). Three of these patients had no preoperative angina, and all 3 died of myocardial failure with reduced cardiac output. In 2 of the patients the coronary arteries were entirely normal at necropsy, and the third had mild, nonobstructive disease. The remaining 5 patients had angina preoperatively. There were no immediate postoperative complications such as persistent ventricular arrhythmias, myocardial infarction or reduced cardiac output that could have been attributed to coronary artery disease in the 50 surviving patients who did not have preoperative angina. Late mortality and morbidity: In Group A, there were 7 late deaths. Three patients had normal coronary arteries and no angina, and died from a cerebrovascular accident, a dissecting aortic aneurysm and an impacted poppet, respectively. The remaining 4 patients had angina preoperatively. One patient with grade I angina and angiographically normal coronary arteries had electrocardiographic evidence of a myocardial infarction after aortic valve replacement. This was presumably due to a coronary embolus that was calcific or thrombotic. None of the deaths or complications, early or late, were due to demonstrable coronary artery disease without preexisting angina. All surviving patients are free of aqgina, including the 2 with coronary obstruction in whom vein bypass graft was avoided. In Group B, there were 9 late deaths. Five patients had no preoperative angina. One died of pacemaker failure after triple valve replacement, and 1 died of arrhythmias due to digitalis toxicity. The third was doing well postoperatively and died suddenly at home, presumably of an arrhythmia. Two patients died with residual left ventricular dysfunction and
Volume 31
CORONARY
ARTERIOGRAMS
congestive heart failure that was not alleviated by double valve replacement. Coronary disease was considered unlikely, and coronary arteriograms were not obtained despite ample opportunity to do so after failure of the condition to improve had become evident. It is doubtful that coronary arteriography would have influenced the management of these patients. The remaining 4 patients had angina preoperatively. Complications of arteriography: One patient had a myocardial infarction documented by electrocardiographic changes and serum enzyme elevations. Persistent chest pain followed injection into the right coronary artery and was probably due to injection of a fibrin clot, since the coronary arteries were normal. The patient recovered, and later had uneventful mitral valve replacement. There were no serious arrhythmias, no arterial injuries and no deaths. Discussion The detection of coronary atherosclerosis in patients with valvular heart disease is no longer of prognostic importance alone, since direct revascularization of the heart by means of aortocoronary bypass grafts may be combined with valvular heart surgery.4 Preoperative coronary arteriography is now routinely performed in many centers.2Ta A review of the findings in 100 patients who had such studies during the past 4 years, and in 78 patients who had valve replacement without such studies, indicates that coronary atherosclerosis significant enough to alter patient management or to require revascularization was apparent clinically. All patients who had critically obstructing coronary arterial lesions had angina pectoris. Thus, if coronary arteriography had been restricted to patients with preoperative angina, there would have been no change in the surgical management of any patient.
Significant coronary arterial obstruction has been shown to correlate closely with the clinical diagnosis of angina pectoris.6 Nonetheless, significant coronary atherosclerosis is occasionally found in asymptomatic persons, and it is pertinent to consider why this was not true of the patients reported here. Our patients with angina pectoris and normal coronary arteries had increased left ventricular work as a result of aortic valve disease, or increased left and right ventricular work (systolic pressure greater than 40 mm Hg) as a result of mitral valve disease. Both of these conditions are known to cause angina in the absence of coronary artery disease.? It is likely that the increased cardiac work load imposed by chronic valvular disease causes increased myocardial oxygen demands. As a result, significant coronary atherosclerosis is unlikely to remain asymptomatic. All survivors in this study were relieved of angina postoperatively, although only 3 in Group A had aortocoronary vein bypass grafts. This symptomatic improvement indicates the adequacy of their coronary blood flow when abnormal cardiac hemodynamics were corrected.
BEFORE
VALVE
REPLACEMENT-BONCHEK
ET AL.
There were no patients with isolated mitral stenosis in this review, since they do not ordinarily require valve replacement. Because patients with pure mitral stenosis and without pulmonary hypertension have no increase in ventricular work-particularly with restricted activity-they may be more likely to have asymptomatic coronary arterial obstruction than other patients with valvular heart disease. Risk factors such as diabetes, hypertension and a family history of atherosclerotic heart disease were too infrequent in our patients to permit statistically significant conclusions, but their proved association with atherosclerosis is such that their presence in an individual patient should cause concern. Although asymptomatic coronary arterial obstruction was not seen in our 178 patients with valvular heart disease, it will inevitably occur. Such patients are more likely to be found amongst those with known risk factors, and it is in these patients that the indications for preoperative arteriography should be the most liberal. The incidence of coronary atherosclerosis in these 178 patients may not be the same in other populations of patients undergoing valve replacement, since the incidence of coronary atherosclerosis is affected by age and sex. A group of patients who are older, or have a higher proportion of men, might have more coronary atherosclerosis than the group reported here. Nonetheless, the relation between angiographic evidence of coronary atherosclerosis and the presence of angina pectoris should be maintained by the mechanisms discussed. Recommendations that coronary arteriography be performed routinely in patients undergoing valve replacement have usually been based upon autopsy findings in patients who died after valve replacement.ls.9 Such findings were believed to indicate that coronary atherosclerosis is a prominent cause of morbidity and mortality after valvular heart surgery. In those studies coronary artery disease was often inferred when myocardial fibrosis was found, yet the two entities are not necessarily synonymous, since fibrosis is often associated with congenital cardiac defects, rheumatic carditis and various cardiopathies.lO (Myocardial fibrosis is found more commonly with mitral valve disease than with aortic valve disease,” probably because mitral disease is more often rheumatic.l) Further, autopsy findings in other studies were not correlated with preoperative symptoms of ischemic heart disease or with the severity of coronary artery disease among survivors of operation. Finally, such recommendations do not consider the risks, expense and discomfort of .routine arteriography. Recently reported experience at the University of Oregon Medical School indicates an incidence of significant cardiac complications (e.g., arrhythmias or infarction) of less than 1 percent, and significant vascular complications (e.g., femoral thrombosis) of 1 percent. Death is much rarer.12 However, such risks vary widely in different clinics in relation to the number of procedures performed.
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Conclusions It may be concluded from our experience that patients with valvular heart disease and no angina are unlikely to have significant coronary obstruction. Coronary arteriography before valve replacement should be performed if the value of the information to be gained outweighs the risks undertaken. At the University of Oregon Medical School, in conjunction with the program of research in valvular heart disease, coronary arteriography may provide valuable insight into operative risk, long-term prognosis and
ET AL.
the functional results of valve replacement. In comparison to the low risk of coronary arteriography in this clinic such information is of value, and we will continue to perform arteriography routinely in patients over 40 years. In clinics where the morbidity and mortality of arteriography are higher, or the information to be gained is less relevant, coronary arteriography may be safely omitted before valve replacement in many patients with increased myocardial work who have no symptoms of ischemic heart disease, and who lack risk factors known to increase its incidence.
References 1. Peterson CR, Herr R, Crisera RV, et al: The failure of hemodynamic improvement after valve replacement surgery. Ann Intern Med 66:1-24, 1967 2. Coleman EH, Soloff LA: Incidence of significant coronary artery disease in rheumatic valvular heart disease. Amer J Cardiol 25:401-404, 1970 3. Lesage CH, Vogel JHK, Bloqnt SG: latrogenic coronary occlusive disease in patients with prosthetic heart valves. Amer J Cardiol 25:123-129. 1970 4. Flemma RJ, Johnson WD, Lepley D, et al: Simultaneous valve replacement and aortocoronary saphenous vein bypass. Ann Thorac Surg 12:163-170, 1971 5. Judklns MP: Percutaneous transfemoral selective coronary arteriography. Radio1 Clin N Amer 6:467-492. 1968 6. Proudfif WL, Shirey EK, Sones FM Jr: Selective tine coronary arteriography: correlation with clinical findings in 1000 patients. Circulation 33:901-910. 1966
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7. Hurst JW, Logue RB: The Heart, Arteries, and Veins, second edition. New York, McGraw-Hill, 1970, p 954 8. Roberts WC, Morrow AG: Late postoperative pathological findings after cardiac valve replacement. Circulation: suppl 1: 35 and 36:48-62, 1967 9. Hodam R, Starr A, Raible D, et al: Totally cloth covered prosthesis: a review of two years’ clinical experience. Circulation: suppl 2: 41 and 42:33-38, 1970 10. Gould SE: Pathology of the Heart and Blood Vessels. Springfield, Ill, Charles C Thomas, 1968, p 240-261, 479526 Il. Flemming HA, Wood P: The myocardial factor in mitral valve disease. Brit Heart J 21 :117-l 22, 1959 12. Green GS, McKinnon CM, Rosch J, et at: Complications of selective percutaneous transfemoral coronary arteriography and their prevention: a review of 445 consecutive examinations. Circulation 65:552-557, 1972
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