Combined valve replacement and myocardial revascularization

Abstract

Combining valve replacement with coronary artery bypass (CABG) for significant concomitant disease remains a controversial subject. To determine the operative results following combined valve replacement and CABG, we evaluated 201 patients seen consecutively between July 1977 and June 1982. CABG for vessels with >70% stenosis was performed with aortic valve replacement in 106 patients, with mitral valve replacement in 82, and with aortic and mitral valve replacement in 13. There were 143 men and 58 women; the mean age was 67 years. Nine operative deaths (8.5%) occurred with aortic valve replacement and CABG: 5 of 25 (20%) when cardioplegia was not used and 4 of 81 (4.9%) with cardioplegia (p < 0.01). The operative mortality rate for isolated aortic valve replacement without coronary disease during the same period was 5.9% (10 of 168). The late actuarial survival rate is similar for aortic valve replacement alone or aortic valve replacement and CABG. There were no operative deaths among patients having undergone aortic and mitral valve replacement and CABG; the rate was 15% (9 of 60) in patients having undergone aortic and mitral replacement without CABG. The operative mortality rate was 21.9% for mitral valve replacement and CABG (18 of 82). Rheumatic disease was present in 14 of these patients, two of whom had early deaths (14.3%), both after repeat mitral operations; 11 mitral valve replacements and CABG were done for degenerative mitral regurgitation with no deaths, and the remaining 57 patients had ischemic mitral regurgitation. Of the latter, 35 had 4+ regurgitation angiographically and were in advanced New York Heart Association (NYHA) class IV—including 19 patients in cardiogenic shock—with 12 hospital deaths (34.3%); 22 had 3+ regurgitation, also NYHA class IV, with four deaths (18.2%). During the same period the operative mortality rate for isolated mitral valve replacement was 17.5% (20 of 114), and the operative mortality rate for isolated CABG in patients with 3+ ischemic mitral regurgitation, whose failure could be controlled medically, was 6.2% (2 of 32). Among this latter group all but two of the late survivors have had an excellent result; two patients required subsequent mitral valve replacement and are doing well. In the absence of ischemic mitral regurgitation, combined CABG with valve replacement for concomitant coronary and valvular disease is associated with an operative mortality and long-term survival rate similar to those of valve replacement for isolated valvular disease; hypothermic cardioplegia adds significantly to the safety of these operations. Ischemic mitral regurgitation, however, may be best treated with revascularization and medical management whenever feasible.