Baak, R (Remon)

Denton, TA

Steyerberg, Ewout

Takkenberg, Hanneke

Trento, A

van Herwerden, LA (Lex)

Takkenberg, Johanna J.M.

Denton, Timothy A.

Baaka, Rémon

Trento, Alfredo

Steyerberg, Ewout W.

van Herwerden, Lex A.

Elsevier - Publisher Connector 

Aortic valve replacement is an established therapy for aor-
tic valve disease, but survival is strongly related to the pres-
ence of coronary artery disease.1,2 In the past decade several
less-invasive techniques have emerged in aortic valve surgery.
These approaches are associated with reduced sternotomy-
related morbidity, but some may cause injury to one or both
internal thoracic arteries (ITAs). The latter could be detri-
mental to the patient who needs coronary artery bypass graft-
ing (CABG) at an older age, since the ITAs no longer can be
used. However, little is known about the need for CABG after
primary isolated aortic valve surgery. The goal of the present
study was to assess the need for CABG after primary isolat-
ed aortic valve surgery and to identify possible predictors of
future CABG at the time of the primary operation.
Methods. We analyzed data of 1598 patients who had pri-
mary isolated aortic valve surgery between 1962 and 1997,
excluding those with previous cardiac operations or concomi-
tant procedures during the aortic valve operation that required
a median sternotomy. The patient data from 2 centers, the
Dijkzigt University Hospital in Rotterdam, The Netherlands
(n = 1004), and Cedars-Sinai Medical Center in Los Angeles,
California (n = 594), were combined to increase sample size
and statistical power and to represent patients from different
health care systems. The probability of long-term survival
and of receiving a CABG operation were estimated by the
method of Kaplan and Meier. In addition, the cumulative
actual incidence of CABG was estimated, adjusting for the
competing risk of death.3
Results. Preoperative and postoperative variables are dis-
played in Table I. Total follow-up was 11,102 patient-years.
Survival was 97% at 1 month, 94% at 1 year, 85% at 5 years,
66% at 10 years (95% confidence interval [CI] 62%-69%),
and 39% at 20 years (95% CI 33%-44%). Only 14 patients
required CABG during follow-up. The median time to CABG
was 8.8 years; median follow-up in those without CABG was
7.2 years. The actuarial probability of receiving a CABG
operation was 1.0% at 10 years and 5.9% at 20 years (CI 3%-
13%) and its cumulative actual incidence was 0.8% at 10
years and 3.1% at 20 years. Univariate analysis showed no
statistically significant effect of age, sex, and surgical center
on freedom from CABG. In patients older than 60 years at the
time of primary aortic valve surgery, a trend toward more re-
operations for CABG was noted (P = .11; log-rank test) with
an actual cumulative risk at 20 years of follow-up of 5.5% in
patients older than 60 years versus 2.6% in patients aged 60
958 Brief communications The Journal of Thoracic and
Cardiovascular Surgery
November 1999
CORONARY ARTERY BYPASS GRAFTING AFTER PRIMARY ISOLATED AORTIC VALVE SURGERY
Johanna J. M. Takkenberg, MD,a Timothy A. Denton, MD,b Rémon Baak,a Alfredo Trento, MD,b Ewout W. Steyerberg, PhD,a
and Lex A. van Herwerden, MD, PhD,a Rotterdam, The Netherlands, and Los Angeles, Calif
From the Division of Cardio-pulmonary Surgery, Heart Center,
Dijkzigt University Hospital, Department of Public Health,
Erasmus University, Rotterdam, The Netherlands,a and the Div-
ision of Cardiothoracic Surgery, Cedars-Sinai Medical Center,
Los Angeles, Calif.b
Received for publication Dec 1, 1998; accepted for publication
June 28, 1999.
Address for reprints: Johanna J. M. Takkenberg, MD, Heart Center,
No. Bd162, Dijkzigt University Hospital, PO Box 2040, 3000 CA
Rotterdam, The Netherlands (E-mail: Takkenberg@thch.azr.nl).
J Thorac Cardiovasc Surg 1999;118:958-9
Copyright © 1999 by Mosby, Inc.
0022-5223/99 $8.00 + 0 12/54/101206
Table I. Comparison of preoperative and postoperative
variables between Rotterdam and Cedars-Sinai
Rotterdam Cedars-Sinai Total
No. of patients 1004 594 1598
Male 675 340 1015
M/F ratio 2.1 1.3* 1.7
Age (y ± SD) 55 ± 17 63 ± 17* 58 ± 17
Mean follow-up (y ± SD) 7.4 ± 5.9 6.2 ± 5.3* 7.0 ± 5.7
Cardiac reoperation (No.) 105 25* 130†
CABG reoperation (No.) 9 5 14†
Follow-up expiration (N) 250 209* 459†
SD, Standard deviation.
*P < .001.
†Log-rank test.
Table II. Characteristics of patients who required
reoperation for CABG
Age at Reop 
Sex primary CABG Maximum 
(M/F) operation (y) (y postop) follow-up (y) Status
M 58 0.2 0.2 Dead
M 51 0.6 18.1 Dead
M 69 3.4 5.7 Alive
M 64 5.1 6.6 Alive
F 70 6.8 7.8 Alive
M 44 8.1 17.7 Alive
M 50 8.7 8.7 Dead
F 58 9.0 10.3 Alive
M 61 11.5 11.6 Dead
M 64 12.0 15.1 Alive
M 66 12.8 12.8 Alive
M 35 17.4 18.8 Alive
F 36 17.8 22.2 Alive
M 62 18.0 18.0 Alive
M/F ratio Mean ± SD Mean ± SD Mean ± SD 
3.7 56 ± 11 y 9 ± 6 y 12 ± 6 y
SD, Standard deviation.
years or younger. Table II shows the characteristics of the 14
patients who required reoperation for CABG. Two of these 14
patients had CABG within 1 year after the primary isolated
aortic valve procedure; 1 died immediately after the operation
and the other 18 years later. The other 12 patients had CABG
3 to 18 years after the initial procedure; 2 died shortly after
the procedure, and the other 10 are still alive.
Comment. In the era of new, less-invasive techniques for
heart valve surgery, concern has been expressed regarding
stretch injury or ligation of the ITAs.4 The use of the ITA
graft in CABG improves survival compared with that provid-
ed by vein grafts alone. This advantage increases with time,
suggesting that the use of the ITA is a more important pre-
dictor of survival than the progression of native coronary dis-
ease.5 However, our data suggest that the concern regarding
the damage to the ITA that may occur in minimally invasive
aortic valve operations is not justified, since CABG after an
initial aortic valve operation is relatively uncommon.
Only 3% of our patients with primary, isolated aortic valve
surgery needed CABG after 20 years of follow-up, compara-
ble with other data published on this subject. Lytle and col-
leagues1 analyzed short- and long-term results in patients
with primary isolated aortic valve replacement. They report-
ed 23 reoperations for CABG in 1689 patients who under-
went primary isolated aortic valve replacement. Of note, 182
of these 1689 patients had coronary artery disease at the time
of the primary operation and did not receive grafts to vessels
with stenoses of 50% or more.
Two patients in our cohort had CABG within 1 year after
the initial aortic valve operation. One of these patients was
operated on in 1973, when it was customary in the
Rotterdam center to apply continuous left coronary artery
perfusion during the operation. This perfusion method most
likely caused proximal left main coronary artery occlusion
necessitating reoperation 6 months after the initial aortic
valve replacement. In our patients, age at primary operation,
sex, and surgical center did not clearly influence CABG inci-
dence, although patients who were older than 60 years at the
time of primary isolated valve operation tended to have more
CABG reoperations. Since the average age of patients re-
quiring aortic valve surgery is steadily increasing,6 our
results may underestimate the true CABG risk, and longer
follow-up may yield a higher CABG risk estimate. Another
limitation of our study is the absence of information on
angioplasty procedures and untreated coronary artery dis-
ease. Also, further studies are necessary to identify other risk
factors for CABG. 
In summary, we have demonstrated that the need for
CABG after primary isolated aortic valve operations is small,
and new, less-invasive surgical techniques that may injure the
ITAs can be applied in most patients. Given the evolution of
arterial grafts (gastroepiploic, superior epigastric, and radial
artery), the small number of patients requiring CABG after
aortic valve operations may still benefit from total arterial
revascularization.
R E F E R E N C E S
1. Lytle BW, Cosgrove DM, Taylor PC, et al. Primary isolated aor-
tic valve replacement: early and late results. J Thorac Cardiovasc
Surg 1989;97:675-94.
2. Czer LSC, Chaux A, Matloff JM, DeRobertis MA, Nessim SA,
Scarlata D. Ten-year experience with the St. Jude Medical valve
for primary valve replacement. J Thorac Cardiovasc Surg
1990;100:44-5.
3. Grunkemeier GL, Anderson RP, Miller DC, Starr A. Time-relat-
ed analysis of nonfatal heart valve complications: cumulative
incidence (actual) versus Kaplan-Meier (actuarial). Circulation
1997;96(Suppl):II70-5.
4. Arom KV, Emery RW. Minimal invasive mitral operations. Ann
Thorac Surg 1997;63:1219-20
5. Cameron A, Davis KB, Green G, Schaff HV. Coronary bypass
surgery with internal-thoracic-artery grafts: effects on survival
over a 15-year period. N Engl J Med 1996;334:216-9.
6. Hokken RB, Steyerberg EW, Verbaan N, van Herwerden LA, van
Domburg R, Bos E. 25 years of aortic valve replacement using
mechanical valves: risk factors for early and late mortality. Eur
Heart J 1997;18:1157-65.
The Journal of Thoracic and
Cardiovascular Surgery
Volume 118, Number 5
Brief communications   959


Coronary artery bypass grafting after primary isolated aortic valve surgery 

EUR Research Repository

Coronary artery bypass grafting after primary isolated aortic valve surgery

file:///data/remote/core/dit/data/elsevier/pdf/334/aHR0cDovL2FwaS5lbHNldmllci5jb20vY29udGVudC9hcnRpY2xlL3BpaS9zMDAyMjUyMjM5OTcwMDcweA==.pdf

Coronary artery bypass grafting after primary isolated aortic valve surgery

Abstract

Similar works

Full text

Available Versions

Elsevier - Publisher Connector

EUR Research Repository

Elsevier - Publisher Connector

EUR Research Repository