Abstract

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Objective: The number of patients doing aortic valve surgery with or without CABG is increasing continuously in our country. The goal of this study is to evaluate the results of aortic valve surgery alone or combined with CABG surgery in terms of mortality and peri operative complications.

Methods: This is a retrospective and prospective study. We included the patients underwent aortic valve surgery (replacement or another procedure)  with or without CABG  from January  2007 and in April 2012 . The population of 243 patients is divided into two groups: Group 1 included 59 patients combined  surgery; Group 2 included 184 patients isolated aortic valve surgery.

Results: The hospital mortality is 4,5 % in general. The hospital mortality for group 1 is 6,8% and for group 2 is 3,8 %. The difference is not statistically significant. Low cardiac output, conduction disturbances, stroke, pulmonary complications, renal complications,  bleeding, atrial fibrillation, wound infections, ventricular arithmias about the complications  are 11.9 % in vs. 7.1 %,5.1% vs 6.6% , 3.4% vs. 0.5 %,13.6  % vs. 3.3%, 5.1 % vs.0.5 % , 5.2 % vs. 1.6 %, 15.3 % vs.17.9%,10.3 % vs 1.6 %,6.8 %vs 6.5 %, respectively for the group 1 and 2.The differences were statistically significant only for pulmonary, renal and wound complications.

Conclusions: We achieved satisfactory results by our experience. Simultaneous coronary artery by-pass with aortic valve increases slightly the operative mortality and perioperative complications . The next goal is to estimate the long term  results for both groups.

Introduction

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Surgery of aortic valve began since the years “80 of the last century treating initially the rheumatic   and infectious pathology of aortic valve continuing later with degenerative one in our country. It has been seen a trend of change of nature of aortic valve pathology toward atherosclerotic etiology in the last two decades with the change of life style, increase of mean age of population and progression of surgical management of old age patients.

Ischemic heart disease is the most frequent pathology that accompanies the pathology of aortic valve and especially aortic valve stenosis [1, 2] and the most frequent intervention coupled with surgical correction of aortic valve pathology is coronary artery by-pass grafting. We tried to expose our experience in surgical treatment of aortic valve pathology combined or not with CABG surgery in this context.

Methods

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This is a retrospective and prospective study. All patients included in this study, underwent intervention in two cardiac surgical centers, the first one is public and the other one a private cardiac surgical center in Tirana. The data were collected from hospital records and registers of hospital statistics.

Preoperative evaluation of risk of intervention is made according to EUROSCORE [3].

Surgical indication for aortic valve and revascularization surgery are decided according to  ESC and AHA/ACC guidelines.[2,4,5].

Mortality and major complications like myocardial infarction, cerebral accidents, pulmonary problems, renal problems, infections etc. are considered  end points for the evaluation of results of surgery of aortic valve alone or combined with by-pass surgery.

Patients

In this study are included 243 patients that underwent surgery of aortic valve alone or in combination with by-pass surgery from January 2007 to April 2012. The population is divided in two groups. Group1 the patients with combined surgery 59 pt. Group 2 the patients with isolated aortic valve surgery 184 pt.

The general demographic and clinical data are presented in table 1. As we can see in the table below mean age of all population in study is 58+/_ 11, 7 years with a higher mean age in group 1; there are 158 males and 85 females; there are not significant differences between groups about the comorbidities except diabetes and hypertension that are more present in group 1 .

Table 1

Baseline characteristics

Transthoracic echocardiography and the cases transesophagicalechocardiography was the main  diagnostictool. We see that there were 140 patients with pure aortic stenosis from the echocardiographic data; 56  patients with aortic insufficiency and the rest of patients had mixed pathology of aortic valve(47 pt). Coronarography was performed according  the guidelines ESC/AHA/ACC [2,4]. The CAD was the primary diagnosis in group 1 in 10 patients.

Echocardiographic data are presented in table 2.

Table 2

There are not differences between two groups in terms of ejection fraction, gradients, aortic valve opening surface ect from the data we see.

Surgical technique

Standard cardiac surgery monitoring was used.

The operation was performed through a complete median sternotomy. Before the institution of cardiopulmonary by-pass the grafts were harvested in group 1.The left internal mammary was harvested in the hemi skeletonized fashion. The saphenous vein was harvested in the standard fashion or using the skin bridge technique.

After heparin administration cardiopulmonary by-pass was instituted, aortic cross clamping ante grade cardioplegia was done.

In group 1 venous coronary artery by-pass was performed first following with the aortic procedure finishing with LIMA grafting. The aortic procedure was performed directly in group 2 normally.

We made always transverse aortotomy. The leaflets were removed and meticulous decalcification was made. Separated suture technique was performed to implant the aortic prosthesis. Sutures Ticron 2/0 with pledged in the aortic face in most cases and in ventricular face in the rest were used. The heart was de-aired and the aortic clamp removed after the closure of the aorta. At the end of the operation the cannulas were removed and protamine was given. Temporary pacemaker (PM) wires and mediastinal and pleural tubes were placed before chest closure.

Statistical analysis

Continuous variables were presented as mean and standard deviation.

Categorical variables were presented in absolute value and percentages. Student t-test for two independent samples was used to analyze the differences between two continuous variable and χ2-test was used to analyze the differences for categorical variables.

A p-value less than 0.05 was considered to be statistically significant.

SPSS (Statistical Package for Social Science) 19.0 was used to analyze data.

Results

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Operative results

Table 3: Intra-operative data

As It is expected we have a longer cardiopulmonary-by-pass and ischemic time in the group with combined surgery figured by the table. The difference is statistically significant. There are used 207 mechanical prosthesis, 35 biological prosthesis and in 5 cases we have done procedures such as in 1 case aortic valve repair, in 4 patients we have done aortic annulus enlargement (Manouguain technique ).

The mean number of grafts is 1,9 +/- 0,9 in the population with combined surgery and the LIMA is used in 39 patients.

We can see from a general view of database that it is an increasing trend of biological prosthesis use.

Hospital mortality and Post-operative morbidity.

The results about early mortality and morbidity that are the primary and secondary respectively endpoints are presented in the table 4.

The overall hospital mortality was 4,5%(11/243). The hospital mortality for Groups 1 and 2was 6.8%(4/59) and 3.8%(7/184), respectively, with no statistical difference (P = 0.29). Mortality in the group with combined surgery is higher but without reaching statistical significance. The overall length of ICU stay and hospital stay is longer in group 1 is importantly longer than for group 2 respectively 111.7+/-26.5 hour,13.2+/-10.6 daysversus  64.4+/-20.6 hours,9.8+/-5.9 days .

About the complications  low cardiac output, conduction disturbances, stroke, pulmonary complications, renal complications,  bleeding, atrial fibrillation, wound infections, ventricular arrhythmias  are 11.9 % in vs. 7.1 %,5.1% vs 6.6% , 3.4% vs. 0.5 %,13.6  % vs. 3.3%, 5.1 % vs.0.5 % , 5.2 % vs. 1.6 %, 15.3 % vs.17.9%,10.3 % vs 1.6 %,6.8 %vs. 6.5 %. respectively for the group 1 and 2.

If we see carefully the results in general we have a greater incidence of complications in group where surgery of aortic valve is accompanied with CABG surgery but only for pulmonary, renal and wound complications,  the difference reaches significance.

Table 4

Discussion

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Aortic valve surgery occupies an important part in surgical activity in different cardiac surgical centers all over the world. The significant increase of the average age of the population in developed countries, but also in our country, has made ??this pathology significantly associated with coronary heart disease. Simultaneous surgical correction of aortic valve pathology and performing Coronary Bypass certainly, increase the complexity of the operation and  influence the early and late  results of   intervention. Performing coronary by-Pass surgery accompanying gestureof aortic valve surgery  has attracted the attention of renowned authors to assess the impact of this gesture in aortic valve  surgery. In  this context, our study has as priority to report the early results of aortic valve surgery isolated or associated with CABG.

European Association for Cardiothoracic Surgery Adult Cardiac Surgery 2010 database provides evidence that the mortality for isolated aortic valve surgery was 3.7% while in  the combination with coronary bypass goes up to 6.2%. [6]. While in long-term, correcting of aortic valve pathology in combination with coronary bypass, significantly improves survival [7].

Based onthe most serious works  in the field of adult cardiac surgery [1] aortic valve surgery mortality is about 4.3%, ranging from 1-8%, while  in combined surgery mortality ranges from 2-10%. There are authors who claim that coronary by-pass associated with aortic valve surgery, increases mortality 1,6-1,8% [8]. CABG appears not as an independent risk factor in both cases.

In an overview of some specific works note that mortality of aortic valve surgery combined with by-pass ranges from 1.9% to 9.4% and mortality in isolated aortic valve surgery ranges from 1.2% to 6.8% [9,10,11,12,13,14,15].

In another paper Dell'Amore et al [16] show us the following data: The overall mortality 5.3%, mortality in the  group with isolated aortic valve surgery  4.3%, while in the group with combined surgery mortality is 7.2%. Regarding the perioperative events: low cardiac output 4.8% vs 18.6%, atrial fibrilation 34% vs 44.3%, stroke 2.7 vs. 3.1%, re-thoracotomy for hemorrhage 5.3 vs 7.2% , renal insufficiency  12.8 vs 16.5% 6.9 vs 10.3% pulmonary problems.

There is a general agreement that coronary by-pass surgery accompanying surgery of aortic valve, increases early mortality but in multi-factorial analysis it turns out not as an independent risk factor. [2].

The total mortality of the population goes up 4.5%, as a result of our study: 3.8% in the group of isolated aortic surgery and goes up to 6.8% in the group with combined surgery. At the same time note that we have a higher incidence of complications where only some of them such as those renal problems, pulmonary problems and wound infection, reach statistical significance. In our opinion, these results can be explained considering the clinical data of patients also by the specifics surgical procedure. We can mention smoking, age, arterial hypertension, diabetes, peripheral arteriopati data, obesity, are more expressed in the group of patients with a combined surgery based in general facts and clinical data. In addition we see that in the combined surgery from the intervention data, we have: longer ischemic and cardio-pulmonary by-pass time, bigger surgical trauma. In these conditions it can be concluded that in combined surgery group we have patients with more comorbidities and more complex surgical procedure. These facts also explain us these results.

Looking our results and comparing them with other works in the same context, note that our results are comparable. By-pass surgery increases mortality in our experience but without reaching statistical significance.

In addition to these facts mentioned above there are also studies with totally different results than talked as above: Kolh et al [17]  report hospital mortality 13% in total, 9% for  isolated aorta and 24% mortality for combined surgery. CABG emerges as an independent risk factor. In the other side Melby et al [18] report lower mortality in combined surgery  6% vs 10% for isolated aortic valve surgery presented  CABG  no as  risk factor but totally on the other hand as a protector.

Another aspect to discuss was about the use of biological prostheses in relation to mechanical prostheses. Now time, it is confirmed a growing trend to use biological prosthesis in accordance with the indications in the developed world [19, 20, 21]. It’s noticed a line with such a trend, even in our experience despite small numbers.

Conclusion(s)

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Isolated aortic valve surgery or combined with surgery of coronary arteries in our country achieved very good results comparable to those of developed countries.

CABG increases mortality when superimposed aortic surgery compared with the latter isolated, without reaching  statistical significance.

Reference(s)

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Source(s) of Funding

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No funding received. 

Competing Interests

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No competing interests.

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