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Aortic Valvular Surgery Associated With
Myocardial Revascularization in Patiens
of 70 Years of Age or Older

Tomasini, Marcos; Ficarra, Alejandro;
Moll, Fernando; Pendino, Diego; Tomasini, Germán

Servicio de Cirugía Torácica y Cardiovascular, Instituto Médico-Quirúrgico
Sanatorio Plaza, Rosario, Santa Fe, Argentina

RESUMEN

SUMMARY
Introduction: The incidence of coronary disease associated to aortic valve disease is approximately 65% and such incidence is increasing with age.
Objectives: To asses the efficacy of myocardial revascularization added to an aortic valve surgery in patients of 70 years of age or older.
Material and Methods: From January 1990 to December 2000, 96 patients were submitted to a combined surgery of aortic valve associated to a myocardial revascularization. Sixty-two patients (64,01%) were male and 34 (35,9) were female patients. The average age was 75,8 years, with a range of 70 to 87 years. Preoperatively all the patients were in functional class III- IV (N.Y.H.A). Six patients had previous cardiac surgery, myocardial revascularization in 5 and aortic valve decalcification- debridement with later restenosis in 1, 25% of the patients were diabetics and 42,4% had carotid disease. Seventy-seven patients (80,2%) received a mechanical valve, bileaflet in 68 and tilting valve in 9. In nine patients a biological valve was implanted, xenograft in 5 and stentless in 4. Ten patients were treated by manual decalcifation- debridenment. In 35 patients, (36,45%) the internal thoracic artery was used to revascularize the anterior descending artery with an average of 2,3 by pass/patient.
Results: The perioperative mortality was 8,3% (8 patients). The follow up period was 73.14 months (average) with a range of 2 and 118 months. Four patients died at 2,6,13 and 14 month respectively. One patient was reoperate at 14 month because of paraprosthetic leak. All the patents who survived the operation are in functional class I-II.
Discussion-Conclusions: The coronary disease associated with aortic valve disease that requires surgical treatment increased the preoperative mortality. The simultaneous myocardial revscularization allows to improve the long term survival without a significant increase in peripoerative mortality.

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INTRODUCTION
   The incidence of coronary artery disease in association to aortic valve disease is approximately 65% and such incidence is increasing with age and varies according to the degree of arterial obstruction considered significant.
Its presence altogether with the aortic valve disease constitutive a significant risk factor in long term survival. As reported by Bonchdek et al and Exadactylos et al the 10 year survival is of 77 % in patients without coronary disease compared to 26% in those with coronary disease.

OBJETIVES
   To asses the efficacy of the myocardial revascularization associated to aortic valve surgery in patients older than 70 years.

MATERIAL AND METHODS
   From january 1990 to december 2000, a series of 96 patients were submitted to a combined surgery of aortic valve to myocardial revascularization. Sixty two patients (64,01%) were male and 34 (35,9%) female patients. The average age was of 75,8 years with a range of 70 to 87 years. Preoperatively all patients were in functional class III or IV. Six patients had previous cardiac surgery, myocardial revascularization in five and aortic valve decalcification with subsecuent restenosis in one, 25% of the patients were diabetic and 42,4% had carotid disease. In 77 patients (80,2%) a mechanical valve was implanted, bileaflet en 68 and monostrut in 9, in nine patients a biological valve was implanted, xenografts in 5 and stentless in 4. Ten patients were treated by means of manual aortic valve debridment. In 35 patients (36,4%) the left internal mammary artery was used to revascularize the anterior descending coronary artery with and average of 2,3 by pass per patient.

RESULTS
   The perioperative mortality was of 8,3% (8 patients), three patients died of stroke, 2 of mediastinitis and 3 because a low cardiac output syndrome, these last patients had a low ejection fraction preoperatively. The average follow up was 73,14 months with a range of 2 to 118 months. Four patients died in the late postoperative period because a bacterial endocarditis of the mitral valve, stroke, heart failure and prosthetic at 2,6,13 and 14 month respectively.

   There were two late reoperation, one patient at 5 months because a paraprosthesic leak with a satisfactory postoperative outcome and the other patient at 14 months, because a prosthetic endocarditis (already mentioned) who died in the postoperative period of multiorganic failure. The rest of the patients are alive and in functional class I or II.

DISCUSSION
   Starr et al. in 1963 reported the first series of patients with aortic valve replacement, and mentioned the coronary disease as a cause of perioperative death in one patient. Years later, Anderson in 1973 emphasized the safety of combined surgical procedure of aortic valve replacement associated with coronary artery by pass. The advent of cardioplegic solutions allow to expand the indications of this type of surgery, lowering its mortality.

   The role of simultaneus myocardial revascularization has been controversial. Although Bonow et al. in 1981 reported the results of 55 patients who had coronary disease associated with valve disease and were submitted to only aortic valve replacement, they had the same 4 year survival as the patients without coronary disease, it is necessary to point out, nevertheless, that most of these patients were young with angiographically moderate coronary disease, with a short term follow up period and a high incidence of residual angor in the surviving patients.

   The patients with coronary disease associated to an aortic valve disease present an advanced functional class and with higher degrees of ventricular disfunction, all our 96 patients were in functional class III and IV.

   The presence of coronary disease per se increases the perioperative death in aortic valve surgery, but the simultaneus myocardial revascularization does not increase it significantly (8,6 patients in our series), but with the demonstrated adventage of improving the long term survival provided that the revascularization was complete and regardless to the severety of the coronary disease.

   In our series of 96 patients, the 36,45% (35 patients), the internal mammary artery was anastomosed to the anterior descending coronary territory, there were no cases of hipoperfusion or low cardiac output syndrome.

   Gall et al. pointed out an increase in the five years survival of 63 % with the use of internal mammary artery compared to 42 % with that of saphenous vein whe used in the descending coronary artery but describe 3 cases of perioperative myocardial infarction. It is imperative to emphasize in these patients of 70 years of age or older with combined disease, the main independent risks factors that affect the long term survival are the age, the compromised ventricular function and the increased cardiothoracic ratio. The use of biologic prosthesis (stentless or stented) or the manual decalcification in patients with advenced age allow a satisfactory survival without the drawbacks and complications inherent to the anticoagulant treatment.

CONCLUSIONS
   The coronary disease associated to the aortic valve disease that requires surgical treatment increases the perioperative death. The simultaneus myocardial revascularization improve the long term survival without a significant increase in the surgical risk. The use of the internal thoracic artery, the biologic prosthesis and the valve decalcification allow a better and greater long term and event free survival.

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Cirugía Valvular Aórtica Asociada a Revascularización Miocárdica en Pacientes Mayores de 70 Años.

RESUMEN
Introducción: La incidencia de enfermedad coronaria asociada a valvulopatía aórtica es aproximadamente del 65% y tal incidencia aumenta con la edad.
Objetivos: Evaluar la eficacia de revascularización miocárdica asociada a cirugía valvular aórtica en pacientes mayores de 70 años.
Material y Métodos: Desde enero de 1990 a diciembre del 2000, 96 pacientes fueron sometidos a cirugía combinada valvular aórtica asociada a revascularización miocárdica. Sesenta y dos pacientes (64,01%) eran del sexo masculino y 34 (35,9%) femenino. La edad promedio fue de 75,8 años con rangos extremos de 70 a 87 años. Preoperatoriamente todos los pacientes se hallaban en clase funcional III- IV. Seis pacientes tenían cirugía cardíaca previa, revascularización miocárdica en 5 y descalcificación valvular aórtica con posterior reestenosis en 1, 25% de los pacientes eran diabéticos y 42,4% tenían enfermedad carotídea. Setenta y siete pacientes (80,2%) recibieron una válvula mecánica, bivalva en 68 y monodisco en 9. Nueve pacientes recibieron una válvula biológica, 5 xenografts y 4 stentless. Diez pacientes fueron tratados mediante descalcificación. En 35 pacientes (36,45%) la arteria mamaria interna fue utilizada para revascularizar la arteria descendente anterior, promedio 2,3 by pass/paciente.
Resultados: La mortalidad perioperatoria fue del 8,3% (8 pacientes). El seguimiento fue de 73,14 meses (promedio) con rango de 2 a 118 meses. Cuatro pacientes fallecieron a los 2,6,13 y 14 meses. Un paciente fue reoperado por insuficiencia paraprotésica. El resto de los pacientes se hallan en clase funcional I y II.
Discusión-Conclusiones: La enfermedad coronaria asociada a la valvulopatía aórtica que requiere tratamiento quirúrgico aumenta la mortalidad perioperatoria. La revascularización miocárdica simultánea permite mejorar la sobrevida a largo plazo sin un incremento significativo en la mortalidad perioperatoria.

 

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
fgaro@fac.org.ar
fgaro@satlink.com
rbretal@fac.org.ar
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