- Email: [email protected]
The Safety of Combined Aortic Valve Replacement and Coronary Bypass Grafting
The Safety of Combined Aortic Valve Replacement and Coronary Bypass Grafting Richard P. Anderson, M.D., Lawrence I. Bonchek, M.D.," James A. Wood, M.D., Richard P. Chapman, M.D., and Albert Starr, M.D. ABSTRACT Coexisting aortic valve disease and atherosclerotic coronary artery disease were treated in 27 patients by combined aortic valve replacement and coronary bypass grafting. There was 1 operative death; 2 late deaths occurred. These results compare favorably with those of either operation performed alone. A modular operative approach was adopted in which each component of the procedure was performed independently in sequence without complicated modifications of proved techniques. Most of the patients have been able to return to full activity following operation. Combined aortic valvular disease and coronary Obstruction should be viewed with optimism. With the utilization of proved techniques this combination can be corrected with safety as indicated by operative mortality and short-term follow-up. ~
A
therosclerotic coronary artery disease is an important cause of death and complications following prosthetic heart valve replacement. Direct revascularization of the heart by means of coronary bypass grafting at the time of valve replacement should reduce this risk, but several recent reports have suggested that the operative mortality of combined operations is appreciably higher than the risk of either operation alone [6, 123. Experience with 27 patients who required aortic valve replacement and aorta-to-coronary artery bypass grafting indicates that combined disease can be safety treated. One operative death and 2 late deaths occurred, and there was gratifying functional improvement in the survivors.
Clinical Material Twenty-seven patients (22 men and 5 women) underwent aortic valve replacement and concomitant aorta-to-coronary artery bypass grafting between January, 1970, and July, 1972, at the University of Oregon Medical School, St. Vincent, and Portland Veterans Administration Hospitals. The From the Division of Cardiopulmonary Surgery, University of Oregon Medical School and Veterans Administration Hospital, Portland, Ore. Supported in part by U.S. Public Health Service Grant No. HE-06336. *Dr. Bonchek is recipient of U.S. Public Health Service Career Development Award H L 70035. Accepted for publication Oct. 16, 1972. Address reprint requests to Dr. Anderson, Division of Cardiopulmonary Surgery, University of Oregon Medical School, 3181 S.W. Sam Jackson Park Rd., Portland, Ore. 97201.
VOL.
15, NO. 3,
MARCH
1973
249
ANDERSON ET AL.
'"F 10
Number of Patients
5
40-49
50-59
60-69
70-79
AGE - Y E A R S
FIG. I . Age distribution in 27 patients undergoing combined aortic value replacement and coronary artery grafting.
ages ranged from 46 to 71 years (mean 58 years), and their distribution is shown in Figure 1. With few exceptions preoperative hemodynamic studies included both left and right heart catheterization and angiocardiograms of the aortic root or left ventricle. Coronary arteriograms in both cine and direct modes were obtained using Judkins' technique [lo]. During this same period, 161 patients had isolated aortic valve replacement and 406 patients received vein grafts. Angina pectoris was present in 26 of the 27 patients and in 7 occurred at rest. Eight patients had had syncopal episodes, and 8 had had previous myocardial infarction. Thirteen patients had been in congestive heart failure; 12 of these were in New York Heart Association Functional Class I11 and 1 was in Class I1 on this basis alone. T h e history and operative findings suggested that the aortic valve disease was clearly rheumatic in 10 patients, calcific or congenital in 15 patients, luetic in 1, and due to prosthetic malfunction in 1. T h e hemodynamic abnormalities are shown in Figure 2. Based on catheterization data and aortography, 7 of the patients had valves that were stenotic, 7 had insufficient valves, and 13 had mixed abnormalities with 100 -
. 0
0
80
-
A O R T I C 60 VALVE GRAD1 E N T mmHg 40
20
-
0-
250
0
00
FIG. 2. T y p e of aortic value disease based on hemodynamic and roentgenographic findings. ( 0 = aortic stenosis, X = aortic insuficiency, o = mixed abnormalities.) Not shown are 4 patients with mixed abnormalities and I patient with aortic stenosis i n whom the left ventricle was not entered at heart catheterization.
0 00 0 0
6% xx xxxxx
THE ANNALS OF THORACIC SURGERY
Aortic Value Replacement and Coronary Grafting
significant stenosis and insufficiency, although one or the other predominated. T h e distribution and severity of the atherosclerotic lesions noted on the arteriogram are shown in Table 1. More than 50% narrowing of the lumen diameter was considered significant and an indication for grafting. However, of 45 vessels in this category, only 5 had less than 70% stenosis. Significant narrowing was found in 18 right coronary arteries, 16 left anterior descending arteries, and 11 circumflex arteries. Single- and double-vessel disease were each seen in 12 patients, while 3 patients had triple-vessel disease. Thus, of 81 major vessels studied angiographically, 45 were significantly obstructed, 13 were mildly diseased, and only 23 were judged normal. At the time of this review, the status of every patient with respect to symptoms and functional capacity was ascertained. Information was collected by direct patient interview, mailed questionnaire, and contact with personal physicians.
Operative Treatment T h e operative approach was modular in concept, with each component performed independently and in sequence without modification of our usual techniques for aortic valve replacement [7, 81 and aorta-to-coronary vein bypass grafting [l]. T h e vein grafts were inserted after valve replacement and were not perfused separately. Operation was performed under high-flow cardiopulmonary bypass (2.4 liters per minute per square meter of body surface area) using a roller pump and a disposable bubble oxygenator. Ventricular fibrillation was induced electrically and the left ventricle vented through an apical catheter. Coronary arteries were perfused for 3- to 4-minute periods every 15 minutes during valve replacement with a composite-seat, totally cloth covered prosthesis (Starr-Edwards Model 23 10 or 2320). TABLE 1. DISTRIBUTION AND SEVERITY OF CORONARY ARTERY DISEASE IN 27 PATIENTS UNDERGOING COMBINED AORTIC VALVE REPLACEMENT AND CORONARY BYPASS GRAFTING
Severity of Disease Severe
(70-10070 stenosis) Moderate (> 50% stenosis < 70%) Mild (< 50% stenosis) Normal
Coronary Distribution (No. of Patients) RCA LAD Circ. 16 (15)" 13 (10) 11 (2)
.,
2 (2).
3 (3)
0
3
5
5
6
6
11
,
I
"The numbers in parentheses represent patients who underwent coronary bypass grafting. RCA = right coronary artery; LAD = left anterior descending coronary artery; Circ. = circumflex coronary artery.
VOL.
15,
NO.
3,
MARCH
1973
251
ANDERSON ET AL.
Following aortic closure, the heart was displaced to expose the coronary anastomotic site. Anastomosis to major vessels was favored, but the posterior descending branch of the right coronary artery or marginal branch of the circumflex artery was grafted when the proximal vessel was diseased. Other secondary branches were not grafted. Reversed autogenous saphenous vein was anastomosed to coronary arteries using 7-0 Dacron sutures impregnated with Teflon. Brief aortic clamping was used when needed to provide a dry field. A total of 32 grafts were inserted (see Table 1). In the right and left anterior descending arteries, 4 of 34 obstructed vessels were not grafted because of obliterative distal disease. However, 9 of 11 obstructed circumflex arteries did not receive grafts, usually because these vessels supplied only small areas of myocardium. Twenty-two patients received a single graft and 5 received a double graft.
Results MORTALITY AND MORBIDITY
There was 1 operative death, that of a 46-year-old man with calcific aortic stenosis and marked left ventricular hypertrophy who required grafts to both the right main and left anterior descending arteries. Low cardiac output resulted in death five days postoperatively. Postmortem examination revealed patency of both grafts and infarction of the entire left ventricle, presumably due to coronary perfusion deficit at operation. There were 2 late deaths. One occurred at fourteen months in a 59-yearold man who received 2 grafts but subsequently developed bacterial endocarditis. He died following disruption of a false aneurysm of the aortic suture line. He was free of angina following operation, and at postmortem examination his right graft was occluded while the anterior descending graft was patent. T h e second death occurred at seventeen months in a 46-year-old man with severe rheumatic aortic insufficiency who developed increasing heart failure six months after operation. Cardiac catheterization showed good prosthetic function and a patent single right graft but very poor left ventricular function, which was attributed to myocardial disease. Four patients showed electrocardiographic evidence of myocardial infarction immediately following operation which was unaccompanied by serious arrhythmia or instability of the circulation. No late myocardial infarctions have been seen. GRAFT PATENCY
Six patients have had repeat coronary arteriography, 2 at three months, 2 at six months, and 1 each at ten and fourteen months after operation. All 7 grafts studied were patent. FUNCTIONAL STATE
The 26 patients surviving operation have been followed for an average of fourteen months (range, one to thirty months). Complete relief of angina 252
THE ANNALS OF THORACIC SURGERY
Aortic Value Replacement and Coronary Grafting
was noted in 23 patients (including both patients who died late but who had no angina following operation and 4 patients operated upon less than two months ago who have not yet resumed full activity). Thirteen patients had symptoms of congestive heart failure prior to operation, and in 3 of these follow-up has been too short (less than two months) to permit evaluation. Among 9 living patients (mean, fifteen months postoperative), 7 were in Class I11 and 2 were in Class I1 before operation. After operation 6 improved to Class I, 1 improved to Class 11, and 2 remained unimproved in Classes I1 and 111, respectively: Improvement from Class I11 to Class I1 was also noted in the patient who suffered a late death from sepsis. The current activity level of the 24 surviving patients is shown in Table 2. Fifteen enjoy full-time employment or unlimited activity, while 1 remains incapacitated because of unrelieved symptoms of congestive heart failure. Activity is limited in 8 patients, 3 of whom are still convalescing less than two months after operation and 5 of whom have persistent symptoms.
Comment Coronary atherosclerosis is often cited as a cause of death or lack of clinical improvement following prosthetic valve replacement [ 11, 131. The reported incidence of coronary atherosclerosis among patients with valvular heart disease varies from 7 to 21y0 [3]. In a recent review [2] of 100 patients who had preoperative coronary arteriography at the University of Oregon Medical School Hospital, 47 patients had aortic valve replacement. In this group, lesions obstructing 60 to lOOyo of the lumen diameter in one or more coronary vessels were found in 5 patients, lesions obstructing less than 60y0 of the lumen diameter in one or more vessels were found in 9 patients, and normal arteries were found in 33 patients. Although asymptomatic coronary obstruction can certainly occur, all patients in the above study who had significant coronary obstruction (more than 60Y0) had angina pectoris. Presumably the excessive left ventricular work load imposed by the aortic valve lesion produced angina by increasing myocardial oxygen needs to a critical level. The important implication of these observations is that patients with angina and valvular heart disease require coronary TABLE 2. FUNCTIONAL STATE IN 24 PATIENTS SURVIVING COMBINED AORTIC VALVE REPLACEMENT AND CORONARY BYPASS GRAFTING
Time Postop." (Yr-) 1.5-2.5 0.5-1.4 < 0.5 Total
Full-Time Employment or Activity
Limited Activity
Incapacitated
3
9
2
0 1 0 1
2
4 15
3 8
'Average time postoperatively, 1.2 years. VOL.
15,
NO.
3,
MARCH
1973
253
ANDERSON ET AL.
arteriography for proper clinical evaluation, even though angina without coronary obstruction frequently accompanies aortic valve disease. T h e only patient in the present series who lacked angina was operated upon for hemolysis secondary to a periprosthetic leak of minor hemodynamic importance. In the absence of an excessive myocardial work load, an asymptomatic but critical coronary lesion was discovered. In view of the considerable burden imposed upon the left ventricle by valve dysfunction, the extent of coexisting disease in the coronary arteries in these patients is striking. More than half the vessels had significant obstruction. Nevertheless, the degree of operability was high in obstructed right and left anterior descending coronary artery systems, with 30 of 34 vessels found suitable for graft insertion. A 1971 report by Flemma and his associates [6] of combined valve replacement and vein grafting described 7 patients with aortic valve disease of whom 6 were operative deaths. Several of their patients had coronary artery disease that was recognized only at operation, and revascularization was performed in a desperate attempt at salvage. T h e authors emphasized the importance of diagnosing coronary obstruction preoperatively. More recently, Morris and co-workers [ 121 reported 15 patients receiving both aortic valves and vein grafts with an operative mortality of 3 patients. Our experience involves 27 patients in whom the mortality compares quite favorably with that of isolated aortic valve replacement or isolated coronary bypass grafting in our own and other clinics [l, 4, 5, 8, 9, 141. These results suggest that the surgical treatment of aortic valve disease and coexisting coronary obstruction can be viewed with optimism. Several factors seem of particular importance in the successful management of these patients. First, preoperative coronary arteriography was obtained in all patients by Judkins’ technique [lo]. T h e outstanding clarity of these studies, especially the direct roentgenograms, allowed selection of sites for graft insertion that maximized outflow by avoiding obstructive lesions distal to the anastomosis. Second, the operative technique, a melding of previously successful methods of valve replacement and vein graft insertion, was unencumbered by distracting and complicated modifications. Finally, the policy of treating all significant coronary disease in each patient, rather than disregarding obstructive lesions in an attempt to shorten the procedure, appeared not to increase operative risk, but on the contrary was usually associated with stability of the circulation in the postoperative period. T h e definition of significant in the preceding statement may be subject to wide interpretation at present. Our usual practice is to graft left anterior descending and dominant right main coronary arteries when narrowing of the transverse diameter by more than 50% is confirmed in several roentgenographic projections and when the distal vascular bed is not obstructed. The circumflex artery is grafted when it appears to be the predominant source of blood supply to the posterior wall of the left ventricle, or when, due to either obliterative disease in the anterior 254
THE ANNALS OF THORACIC SURGERY
Aortic Value Replacement and Coronary Grafting
descending artery or prominence of the circumflex marginal branch, it becomes important in supplying the anterolateral wall. Recently we have not grafted vessels narrowed to 50 to 60% in patients of advanced age with high valvular pressure gradients, relying on relief of valve obstruction alone to accomplish symptomatic improvement. T h e clinical response to operation has been gratifying. Only 3 patients have residual, although diminished, angina. Among 9 patients with heart failure preoperatively, 7 are improved to Functional Class I or 11. Fifteen of the 21 patients alive more than two months after operation have resumed the full activities of normal living.
References 1. Anderson, R. P., Hodam, R., Wood, J., and Starr, A. Direct revascularization of the heart: Early clinical experience with 200 patients. J. Thorac. Cardiovasc. Surg. 63353, 1972. 2. Bonchek, L. I., Anderson, R. P., and Rosch, J. Should coronary arteriograms be performed routinely prior to valve replacement? Am. J. Cardiol. In press. 3. Coleman, E. H., and Soloff, L. A. Incidence of significant coronary disease in rheumatic valvular heart disease. Am. J. Cardiol. 25~401,1970. 4. Duvoisin, G. E., Wallace, R. B., Ellis, F. H., Anderson, M. W., and McGoon, D. C. Late results of cardiac valve replacement. Circulation 37 (Suppl. II):75, 1968. 5. Effler, D. B., Favaloro, R. G., Groves, L. K., and Loop, F. D. The simple approach to direct coronary artery surgery: Cleveland Clinic experience. J. Thorac. Cardiovasc. Surg. 62:503, 1971. 6. Flemma, R. J., Johnson, W. D., Lepley, D., Jr., Auer, J. E., Tector, A. J., and Blitz, J. Simultaneous valve replacement and aorta-to-coronary saphenous vein bypass. Ann. Thorac. Surg. 12:163, 1971. 7. Herr, R. H., Starr, A., Pierie, W. R., Wood, J. A., and Bigelow, J. C. Aortic valve replacement: A review of six years' experience with the ball-valve prosthesis. Ann. Thorac. Surg. 6: 199, 1968. 8. Hodam, R., Anderson, R., Starr, A., Wood, J., Dobbs, J., and Raible, D. Further evaluation of the composite seat cloth-covered aortic prosthesis. Ann. Thorac. Surg. 12:621, 1971. 9. Isom, 0. W., Williams, C. D., Falk, E. A., and Spencer, F. C. Long-Term Evaluation of Cloth-covered Metallic Ball Prosthesis. Presented at the 53rd Annual Meeting of The American Association for Thoracic Surgery, May, 1972. 10. Judkins, M. P. Percutaneous transfemoral selective coronary arteriography. Radaol. Clin. North A m . 6:467, 1968. 11. Linhart, J. W., and Wheat, M. W. Myocardial dysfunction following aortic valve replacement: The significance of coronary artery disease. J. Thorac. Cardiovasc. Surg. 54259, 1967. 12. Morris, G. C., Howell, J, F., Crawford, E. S., Reul, G. J., and Stelter, W. Operability of end stage coronary artery disease. Ann. Surg. 175:1024, 1972. 13. Peterson, C. R., Herr, R., Crisera, R. V., Starr, A., Bristow, J. D., and Griswold, H. E. The failure of hemodynamic improvement after valve replacement surgery: Etiology, diagnosis, and treatment. Ann. Intern. Med. 66:1, 1967. 14. Spencer, F. C., Green, G. E., Tice, D. A., and Glassman, E. Bypass grafting for occlusive disease of the coronary arteries: A report of experience with 195 patients. Ann. Surg. 173:1029, 1971.
A
therosclerotic coronary artery disease is an important cause of death and complications following prosthetic heart valve replacement. Direct revascularization of the heart by means of coronary bypass grafting at the time of valve replacement should reduce this risk, but several recent reports have suggested that the operative mortality of combined operations is appreciably higher than the risk of either operation alone [6, 123. Experience with 27 patients who required aortic valve replacement and aorta-to-coronary artery bypass grafting indicates that combined disease can be safety treated. One operative death and 2 late deaths occurred, and there was gratifying functional improvement in the survivors.
Clinical Material Twenty-seven patients (22 men and 5 women) underwent aortic valve replacement and concomitant aorta-to-coronary artery bypass grafting between January, 1970, and July, 1972, at the University of Oregon Medical School, St. Vincent, and Portland Veterans Administration Hospitals. The From the Division of Cardiopulmonary Surgery, University of Oregon Medical School and Veterans Administration Hospital, Portland, Ore. Supported in part by U.S. Public Health Service Grant No. HE-06336. *Dr. Bonchek is recipient of U.S. Public Health Service Career Development Award H L 70035. Accepted for publication Oct. 16, 1972. Address reprint requests to Dr. Anderson, Division of Cardiopulmonary Surgery, University of Oregon Medical School, 3181 S.W. Sam Jackson Park Rd., Portland, Ore. 97201.
VOL.
15, NO. 3,
MARCH
1973
249
ANDERSON ET AL.
'"F 10
Number of Patients
5
40-49
50-59
60-69
70-79
AGE - Y E A R S
FIG. I . Age distribution in 27 patients undergoing combined aortic value replacement and coronary artery grafting.
ages ranged from 46 to 71 years (mean 58 years), and their distribution is shown in Figure 1. With few exceptions preoperative hemodynamic studies included both left and right heart catheterization and angiocardiograms of the aortic root or left ventricle. Coronary arteriograms in both cine and direct modes were obtained using Judkins' technique [lo]. During this same period, 161 patients had isolated aortic valve replacement and 406 patients received vein grafts. Angina pectoris was present in 26 of the 27 patients and in 7 occurred at rest. Eight patients had had syncopal episodes, and 8 had had previous myocardial infarction. Thirteen patients had been in congestive heart failure; 12 of these were in New York Heart Association Functional Class I11 and 1 was in Class I1 on this basis alone. T h e history and operative findings suggested that the aortic valve disease was clearly rheumatic in 10 patients, calcific or congenital in 15 patients, luetic in 1, and due to prosthetic malfunction in 1. T h e hemodynamic abnormalities are shown in Figure 2. Based on catheterization data and aortography, 7 of the patients had valves that were stenotic, 7 had insufficient valves, and 13 had mixed abnormalities with 100 -
. 0
0
80
-
A O R T I C 60 VALVE GRAD1 E N T mmHg 40
20
-
0-
250
0
00
FIG. 2. T y p e of aortic value disease based on hemodynamic and roentgenographic findings. ( 0 = aortic stenosis, X = aortic insuficiency, o = mixed abnormalities.) Not shown are 4 patients with mixed abnormalities and I patient with aortic stenosis i n whom the left ventricle was not entered at heart catheterization.
0 00 0 0
6% xx xxxxx
THE ANNALS OF THORACIC SURGERY
Aortic Value Replacement and Coronary Grafting
significant stenosis and insufficiency, although one or the other predominated. T h e distribution and severity of the atherosclerotic lesions noted on the arteriogram are shown in Table 1. More than 50% narrowing of the lumen diameter was considered significant and an indication for grafting. However, of 45 vessels in this category, only 5 had less than 70% stenosis. Significant narrowing was found in 18 right coronary arteries, 16 left anterior descending arteries, and 11 circumflex arteries. Single- and double-vessel disease were each seen in 12 patients, while 3 patients had triple-vessel disease. Thus, of 81 major vessels studied angiographically, 45 were significantly obstructed, 13 were mildly diseased, and only 23 were judged normal. At the time of this review, the status of every patient with respect to symptoms and functional capacity was ascertained. Information was collected by direct patient interview, mailed questionnaire, and contact with personal physicians.
Operative Treatment T h e operative approach was modular in concept, with each component performed independently and in sequence without modification of our usual techniques for aortic valve replacement [7, 81 and aorta-to-coronary vein bypass grafting [l]. T h e vein grafts were inserted after valve replacement and were not perfused separately. Operation was performed under high-flow cardiopulmonary bypass (2.4 liters per minute per square meter of body surface area) using a roller pump and a disposable bubble oxygenator. Ventricular fibrillation was induced electrically and the left ventricle vented through an apical catheter. Coronary arteries were perfused for 3- to 4-minute periods every 15 minutes during valve replacement with a composite-seat, totally cloth covered prosthesis (Starr-Edwards Model 23 10 or 2320). TABLE 1. DISTRIBUTION AND SEVERITY OF CORONARY ARTERY DISEASE IN 27 PATIENTS UNDERGOING COMBINED AORTIC VALVE REPLACEMENT AND CORONARY BYPASS GRAFTING
Severity of Disease Severe
(70-10070 stenosis) Moderate (> 50% stenosis < 70%) Mild (< 50% stenosis) Normal
Coronary Distribution (No. of Patients) RCA LAD Circ. 16 (15)" 13 (10) 11 (2)
.,
2 (2).
3 (3)
0
3
5
5
6
6
11
,
I
"The numbers in parentheses represent patients who underwent coronary bypass grafting. RCA = right coronary artery; LAD = left anterior descending coronary artery; Circ. = circumflex coronary artery.
VOL.
15,
NO.
3,
MARCH
1973
251
ANDERSON ET AL.
Following aortic closure, the heart was displaced to expose the coronary anastomotic site. Anastomosis to major vessels was favored, but the posterior descending branch of the right coronary artery or marginal branch of the circumflex artery was grafted when the proximal vessel was diseased. Other secondary branches were not grafted. Reversed autogenous saphenous vein was anastomosed to coronary arteries using 7-0 Dacron sutures impregnated with Teflon. Brief aortic clamping was used when needed to provide a dry field. A total of 32 grafts were inserted (see Table 1). In the right and left anterior descending arteries, 4 of 34 obstructed vessels were not grafted because of obliterative distal disease. However, 9 of 11 obstructed circumflex arteries did not receive grafts, usually because these vessels supplied only small areas of myocardium. Twenty-two patients received a single graft and 5 received a double graft.
Results MORTALITY AND MORBIDITY
There was 1 operative death, that of a 46-year-old man with calcific aortic stenosis and marked left ventricular hypertrophy who required grafts to both the right main and left anterior descending arteries. Low cardiac output resulted in death five days postoperatively. Postmortem examination revealed patency of both grafts and infarction of the entire left ventricle, presumably due to coronary perfusion deficit at operation. There were 2 late deaths. One occurred at fourteen months in a 59-yearold man who received 2 grafts but subsequently developed bacterial endocarditis. He died following disruption of a false aneurysm of the aortic suture line. He was free of angina following operation, and at postmortem examination his right graft was occluded while the anterior descending graft was patent. T h e second death occurred at seventeen months in a 46-year-old man with severe rheumatic aortic insufficiency who developed increasing heart failure six months after operation. Cardiac catheterization showed good prosthetic function and a patent single right graft but very poor left ventricular function, which was attributed to myocardial disease. Four patients showed electrocardiographic evidence of myocardial infarction immediately following operation which was unaccompanied by serious arrhythmia or instability of the circulation. No late myocardial infarctions have been seen. GRAFT PATENCY
Six patients have had repeat coronary arteriography, 2 at three months, 2 at six months, and 1 each at ten and fourteen months after operation. All 7 grafts studied were patent. FUNCTIONAL STATE
The 26 patients surviving operation have been followed for an average of fourteen months (range, one to thirty months). Complete relief of angina 252
THE ANNALS OF THORACIC SURGERY
Aortic Value Replacement and Coronary Grafting
was noted in 23 patients (including both patients who died late but who had no angina following operation and 4 patients operated upon less than two months ago who have not yet resumed full activity). Thirteen patients had symptoms of congestive heart failure prior to operation, and in 3 of these follow-up has been too short (less than two months) to permit evaluation. Among 9 living patients (mean, fifteen months postoperative), 7 were in Class I11 and 2 were in Class I1 before operation. After operation 6 improved to Class I, 1 improved to Class 11, and 2 remained unimproved in Classes I1 and 111, respectively: Improvement from Class I11 to Class I1 was also noted in the patient who suffered a late death from sepsis. The current activity level of the 24 surviving patients is shown in Table 2. Fifteen enjoy full-time employment or unlimited activity, while 1 remains incapacitated because of unrelieved symptoms of congestive heart failure. Activity is limited in 8 patients, 3 of whom are still convalescing less than two months after operation and 5 of whom have persistent symptoms.
Comment Coronary atherosclerosis is often cited as a cause of death or lack of clinical improvement following prosthetic valve replacement [ 11, 131. The reported incidence of coronary atherosclerosis among patients with valvular heart disease varies from 7 to 21y0 [3]. In a recent review [2] of 100 patients who had preoperative coronary arteriography at the University of Oregon Medical School Hospital, 47 patients had aortic valve replacement. In this group, lesions obstructing 60 to lOOyo of the lumen diameter in one or more coronary vessels were found in 5 patients, lesions obstructing less than 60y0 of the lumen diameter in one or more vessels were found in 9 patients, and normal arteries were found in 33 patients. Although asymptomatic coronary obstruction can certainly occur, all patients in the above study who had significant coronary obstruction (more than 60Y0) had angina pectoris. Presumably the excessive left ventricular work load imposed by the aortic valve lesion produced angina by increasing myocardial oxygen needs to a critical level. The important implication of these observations is that patients with angina and valvular heart disease require coronary TABLE 2. FUNCTIONAL STATE IN 24 PATIENTS SURVIVING COMBINED AORTIC VALVE REPLACEMENT AND CORONARY BYPASS GRAFTING
Time Postop." (Yr-) 1.5-2.5 0.5-1.4 < 0.5 Total
Full-Time Employment or Activity
Limited Activity
Incapacitated
3
9
2
0 1 0 1
2
4 15
3 8
'Average time postoperatively, 1.2 years. VOL.
15,
NO.
3,
MARCH
1973
253
ANDERSON ET AL.
arteriography for proper clinical evaluation, even though angina without coronary obstruction frequently accompanies aortic valve disease. T h e only patient in the present series who lacked angina was operated upon for hemolysis secondary to a periprosthetic leak of minor hemodynamic importance. In the absence of an excessive myocardial work load, an asymptomatic but critical coronary lesion was discovered. In view of the considerable burden imposed upon the left ventricle by valve dysfunction, the extent of coexisting disease in the coronary arteries in these patients is striking. More than half the vessels had significant obstruction. Nevertheless, the degree of operability was high in obstructed right and left anterior descending coronary artery systems, with 30 of 34 vessels found suitable for graft insertion. A 1971 report by Flemma and his associates [6] of combined valve replacement and vein grafting described 7 patients with aortic valve disease of whom 6 were operative deaths. Several of their patients had coronary artery disease that was recognized only at operation, and revascularization was performed in a desperate attempt at salvage. T h e authors emphasized the importance of diagnosing coronary obstruction preoperatively. More recently, Morris and co-workers [ 121 reported 15 patients receiving both aortic valves and vein grafts with an operative mortality of 3 patients. Our experience involves 27 patients in whom the mortality compares quite favorably with that of isolated aortic valve replacement or isolated coronary bypass grafting in our own and other clinics [l, 4, 5, 8, 9, 141. These results suggest that the surgical treatment of aortic valve disease and coexisting coronary obstruction can be viewed with optimism. Several factors seem of particular importance in the successful management of these patients. First, preoperative coronary arteriography was obtained in all patients by Judkins’ technique [lo]. T h e outstanding clarity of these studies, especially the direct roentgenograms, allowed selection of sites for graft insertion that maximized outflow by avoiding obstructive lesions distal to the anastomosis. Second, the operative technique, a melding of previously successful methods of valve replacement and vein graft insertion, was unencumbered by distracting and complicated modifications. Finally, the policy of treating all significant coronary disease in each patient, rather than disregarding obstructive lesions in an attempt to shorten the procedure, appeared not to increase operative risk, but on the contrary was usually associated with stability of the circulation in the postoperative period. T h e definition of significant in the preceding statement may be subject to wide interpretation at present. Our usual practice is to graft left anterior descending and dominant right main coronary arteries when narrowing of the transverse diameter by more than 50% is confirmed in several roentgenographic projections and when the distal vascular bed is not obstructed. The circumflex artery is grafted when it appears to be the predominant source of blood supply to the posterior wall of the left ventricle, or when, due to either obliterative disease in the anterior 254
THE ANNALS OF THORACIC SURGERY
Aortic Value Replacement and Coronary Grafting
descending artery or prominence of the circumflex marginal branch, it becomes important in supplying the anterolateral wall. Recently we have not grafted vessels narrowed to 50 to 60% in patients of advanced age with high valvular pressure gradients, relying on relief of valve obstruction alone to accomplish symptomatic improvement. T h e clinical response to operation has been gratifying. Only 3 patients have residual, although diminished, angina. Among 9 patients with heart failure preoperatively, 7 are improved to Functional Class I or 11. Fifteen of the 21 patients alive more than two months after operation have resumed the full activities of normal living.
References 1. Anderson, R. P., Hodam, R., Wood, J., and Starr, A. Direct revascularization of the heart: Early clinical experience with 200 patients. J. Thorac. Cardiovasc. Surg. 63353, 1972. 2. Bonchek, L. I., Anderson, R. P., and Rosch, J. Should coronary arteriograms be performed routinely prior to valve replacement? Am. J. Cardiol. In press. 3. Coleman, E. H., and Soloff, L. A. Incidence of significant coronary disease in rheumatic valvular heart disease. Am. J. Cardiol. 25~401,1970. 4. Duvoisin, G. E., Wallace, R. B., Ellis, F. H., Anderson, M. W., and McGoon, D. C. Late results of cardiac valve replacement. Circulation 37 (Suppl. II):75, 1968. 5. Effler, D. B., Favaloro, R. G., Groves, L. K., and Loop, F. D. The simple approach to direct coronary artery surgery: Cleveland Clinic experience. J. Thorac. Cardiovasc. Surg. 62:503, 1971. 6. Flemma, R. J., Johnson, W. D., Lepley, D., Jr., Auer, J. E., Tector, A. J., and Blitz, J. Simultaneous valve replacement and aorta-to-coronary saphenous vein bypass. Ann. Thorac. Surg. 12:163, 1971. 7. Herr, R. H., Starr, A., Pierie, W. R., Wood, J. A., and Bigelow, J. C. Aortic valve replacement: A review of six years' experience with the ball-valve prosthesis. Ann. Thorac. Surg. 6: 199, 1968. 8. Hodam, R., Anderson, R., Starr, A., Wood, J., Dobbs, J., and Raible, D. Further evaluation of the composite seat cloth-covered aortic prosthesis. Ann. Thorac. Surg. 12:621, 1971. 9. Isom, 0. W., Williams, C. D., Falk, E. A., and Spencer, F. C. Long-Term Evaluation of Cloth-covered Metallic Ball Prosthesis. Presented at the 53rd Annual Meeting of The American Association for Thoracic Surgery, May, 1972. 10. Judkins, M. P. Percutaneous transfemoral selective coronary arteriography. Radaol. Clin. North A m . 6:467, 1968. 11. Linhart, J. W., and Wheat, M. W. Myocardial dysfunction following aortic valve replacement: The significance of coronary artery disease. J. Thorac. Cardiovasc. Surg. 54259, 1967. 12. Morris, G. C., Howell, J, F., Crawford, E. S., Reul, G. J., and Stelter, W. Operability of end stage coronary artery disease. Ann. Surg. 175:1024, 1972. 13. Peterson, C. R., Herr, R., Crisera, R. V., Starr, A., Bristow, J. D., and Griswold, H. E. The failure of hemodynamic improvement after valve replacement surgery: Etiology, diagnosis, and treatment. Ann. Intern. Med. 66:1, 1967. 14. Spencer, F. C., Green, G. E., Tice, D. A., and Glassman, E. Bypass grafting for occlusive disease of the coronary arteries: A report of experience with 195 patients. Ann. Surg. 173:1029, 1971.