Trevor C. Chopko DO MS, Fazal W. Khan MBBS, John M. Stulak MD, Arman Arghami MD MPH
Mayo Clinic
November 25, 2024
Abbreviations and Definitions
AR – Aortic regurgitation
AS – Aortic stenosis
AVR – Aortic valve replacement
CABG – Coronary artery bypass grafting
CAD – Coronary artery disease
DVR – Double valve replacement
GDMT – Goal-directed medical therapy
HF – Heart failure
LAD – Left anterior descending artery
LVEF – Left ventricular ejection fraction
MR – Mitral regurgitation
MS – Mitral stenosis
MVR – Mitral valve replacement
MVr – Mitral valve repair
NYHA – New York Heart Association
OPCAB – Off-pump coronary artery bypass
PCI – Percutaneous coronary intervention
TAVI – Transcatheter aortic valve intervention
Indications and Guidelines for Management
In patients suffering from both coronary artery disease (CAD) and valvular pathology, it is reasonable to pursue concomitant coronary artery bypass grafting (CABG) and valve repair/replacement under one anesthetic and cardiopulmonary bypass event. This approach reduces the procedural, financial, and mental burden for patients. CAD is commonly found in patients with valvular dysfunction, and untreated CAD is associated with worse outcomes in patients undergoing isolated transcatheter or surgical valve replacement.1-4 Additionally, improvements in diagnostics and preoperative optimization have increased surgeon comfort with simultaneous CABG and aortic valve replacement (AVR), mitral valve replacement/repair (MVR/r), or double valve repair/replacement (DVR). It is worth noting that combining CABG and valve repair/replacement is associated with increased morbidity, mortality, and reduced survival compared to CABG or valve repair/replacement in isolation.4-9 However, this increased risk is attributable to the fact that the patient has a more complex disease process involving both valves and coronaries, in addition to the complexity of a combined CABG and valve repair/replacement procedure. Irrespective, one of the strongest predictors of early death in CAD patients undergoing valve repair/replacement is omitting revascularization.10-12 Thus, when feasible, combined CABG and valve repair/replacement should be pursued in select candidates.
Table 1. Indications for CABG, AVR, MVR/r, and DVR.13-18
| Surgery | Indications | Class | Refs |
|---|---|---|---|
| CABG | Significant left main coronary artery stenosis Comorbid diabetes with multi-vessel disease involving the LAD Multi-vessel disease |
I I IIA | 13 |
| and/or | |||
| AVR | Severe AS (Stage C1) that are undergoing cardiac surgery for other indications Severe AR (Stage C/D) that are undergoing cardiac surgery for other indications In patients with an indication for AVR, the choice of the prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences, including a discussion of the indications/risks of anticoagulation and the potential need for/risks associated with valve reintervention Moderate AR (Stage B) patients undergoing cardiac or aortic surgery for other indications Moderate AS (Stage B) patients undergoing cardiac surgery for other indications Rapid progression of transvalvular gradients (>10 mmHg/year of >0.3m/s/year) in AS and CAD A hybrid approach combining OPCAB and TAVI is a safe and feasible in high-risk patients with severe AS and CAD | I
I I IIA IIB IIA N/A |
14-16 |
| MVR/r | Symptomatic patients (NYHA Class III/IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) that require other cardiac procedures Severe secondary MR (Stages C and D) with CABG for the treatment of myocardial ischemia In patients with CAD and chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%) (Stage D) that are undergoing mitral valve surgery because of severe symptoms (NYHA Class III/IV) that persist despite GDMT for HF, chordal-sparing MVR may be reasonable compared to downsized annuloplasty repair | I
IIA IIB |
14, 17-18 |
| DVR | Same as above | ||
Combined CABG and AVR
Combined CABG and AVR is the fifth most common cardiac surgery behind isolated CABG and AVR.19 Aortic stenosis (AS) is the most common valvular pathology in high-income countries, and its prevalence increases with age, affecting 3.9% of patients in their 70s and 9.8% of patients in their 80s.20, 21 Aortic regurgitation (AR) has a prevalence of 4.9% and accounts for approximately 50% of AVRs in the United States.22 CAD is similarly ubiquitous in this patient population, affecting 40-60% of elderly patients referred for cardiac valve surgery.23 Thus, simultaneous AVR and CABG are viable options in this patient population. A meta-analysis of 176 studies comparing AVR and CABG to AVR alone found an operative risk, stroke rate, pacemaker implantation rate, and dialysis requirement of 5.5%, 3.0%, 3.9%, and 5.6% in the former, compared to 3.3%, 1.7%, 3.3% and 1.6% in the latter.24 In patients >80 years old, special consideration is warranted as meta-analyses found a 9.7% immediate mortality, with a postoperative stroke rate of 3.7% and a pacemaker implantation rate of 4.3%. The 1-, 3-, 5-, and 10-year survival rates following AVR and CABG are 83.2%, 72.9%, 60.8%, and 25.7%, respectively.23
Interventional approaches, such as percutaneous coronary intervention (PCI) and transcatheter aortic valve intervention (TAVI), are increasingly utilized beyond high-risk and inoperable patients. Between 2016 and 2019, there was a 2-4% annual increase in the combined procedure.25 A recent meta-analysis including 7 studies with over 3,700 patients compared staged versus concomitant TAVI/PCI, finding no difference in 30-day mortality, length of stay, renal failure, stroke, and intraoperative blood loss.26 However, pacemaker implantation was increased in the staged approach, suggesting concomitant TAVI/PCI may be superior. Retrospective multivariate analysis of staged versus concomitant TAVI/PCI utilizing the National Readmission Database between 2016-2018 corroborated a preference towards the concomitant approach.27 Identified were similar rates of in-hospital mortality, pacemaker implantation, stroke, and intraoperative blood loss, but increased acute kidney injury, length of stay, and cost in the staged approach. Few studies with variable results have directly compared the surgical and interventional combined procedures. Retrospective propensity-score matching meta-analysis revealed significantly lower major adverse cardiovascular events (OR 0.72, CI 0.62-0.83) and all-cause mortality (OR 0.68, CI 0.57-0.81) with TAVI/PCI compared to SAVR/CABG.25 However, this benefit reversed at 30 days in both major adverse cardiovascular events (OR 1.40, CI 1.05-1.87) and mortality (OR 1.75, CI 1.22-2.50) in the TAVI/PCI cohort. Pacemaker implantation and perivalvular leak are additionally increased in the TAVI/PCI group.11 In patients with concomitant triple-vessel CAD and AS, surgical AVR and CABG are preferred.28 To elucidate the efficacy and safety profile, further larger-scale studies, meta-analyses, and clinical trials are warranted.
Combined CABG and MVR/r
Mitral valve surgery includes repair or replacement, where repair has better long-term outcomes when possible.17, 18 Approximately 15% of patients undergoing MVR/r have significant CAD, defined as >50% stenosis.29 Due to this reduced incidence, combined CABG and MVR/r occur much less frequently than their aortic counterparts with a similarly comorbid population. The pathophysiology of mitral regurgitant disease stratifies patient risk, as the degenerative disease is associated with lower mortality and superior long-term survival than ischemia.7 Degenerative disease results from rheumatic heart disease, collagen disorders, calcification, or trauma. Ischemic mitral regurgitation (MR) is caused by left ventricular remodeling and annular dilation and is found in nearly half of myocardial infarction patients, with approximately 10% developing moderate MR.30, 31 Mitral stenosis (MS) is typically caused by rheumatic heart disease and increases left atrial pressure, reducing cardiac output and predisposing to pulmonary hypertension and secondary tricuspid regurgitation (TR).
Degenerative mitral valve disease has conflicting results on the risks and benefits of combined surgery when compared to isolated MVR. Multivariate analysis revealed combined surgery, compared to isolated MVR, was independently associated with an increased operative (11.2% vs 2.5%, p<0.001), 1-year (85% vs 96%, p=0.041), and 5-year (78% vs 87%, p=0.041) mortality as well as morbidity (53.4% vs 18.9%, p<0.001), but not 8-year mortality.32 However, additional propensity score-matching analysis found no difference between isolated MVR and combined surgery in terms of in-hospital mortality, stroke risk, dialysis risk, reoperation, hospital length of stay, or 10-year survival.7 In terms of ischemic MR, a meta-analysis including 9 studies with 2,479 patients revealed no improvement in late mortality or postoperative NYHA functional class with combined surgery, despite lower MR grades.33 Another meta-analysis utilizing six randomized controlled trials in moderate ischemic MR found no statistical difference between combined surgery and isolated CABG in terms of operative and 1-year mortality, postoperative stroke risk, and reoperation.34 These studies suggest ischemic MR may be appropriately treated with CABG alone; however, severe ischemic MR should be addressed with MVR,14, 17, 18 whereas combined MVR and CABG in degenerative mitral disease may not carry an increased risk from the combined procedure.
Combined CABG and DVR
Concomitant mitral and aortic valve disease commonly occurs as a sequelae of rheumatic heart disease in younger patients or calcific degeneration in older patients. It is imperative to determine the underlying cardiac function, as presenting symptoms may demonstrate irreversible heart failure. The in-hospital mortality is 6.7-7.0%, and the cardiac event-free survival at 1- and 4-years is 77.3% and 64.6%, respectively.35, 36 Independent predictors of cardiac event-free survival were age and previous myocardial infarction.36
Expert Commentary
Patients requiring combined valve and coronary surgery are typically at higher risk due to their underlying disease status and the complexity of the procedure. While the indications for both PCI and TAVI have expanded, a combination of three-vessel disease and severe AS can benefit from a combined AVR and CABG to address all pathologies in a single setting. This approach may offer the potential benefit of addressing both conditions comprehensively through surgery.
CAD in the context of degenerative mitral valve disease is generally regarded as two distinct disease processes. However, functional ischemic MR associated with CAD presents a more complex challenge. This condition is associated with poorer outcomes and requires meticulous evaluation and planning to optimize treatment strategies.
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