The older you get, the closer you are to death

—an

old Asian saying

In 1994-96, three studies described patients who had previously undergone coronary artery bypass graft surgery (CABG) and then had subsequent aortic valve replacement (AVR) (the aortic stenosis was “mild to moderate” at time of initial CABG); these patients were subsequently associated with a “high” operative mortality of 14–19%.1-3

From these studies arose the rationale that patients who have mild to moderate aortic stenosis at the time of CABG will develop severe aortic stenosis within 10 years; such patients should therefore have combined CABG+AVR at time of initial bypass surgery.1-3

There were several problems with this rationale, which have been previously described in detail and are summarised below.4

• Two subsequent studies showed that the operative mortality for later AVR, if necessary, was not significantly different from those undergoing CABG+AVR (0% and 7.7%).5 ,6

• Most importantly, these studies provided no information on the numbers of patients during the same time period who had mild to moderate aortic stenosis but did not require AVR during subsequent follow up.4 ,7

• There was little or no documentation to show that the aortic stenosis was mild to moderate at the time of the initial CABG. Moreover, some patients already had severe aortic stenosis at the time of initial CABG which was misdiagnosed.4

• At time of subsequent AVR, the documentation showing that aortic stenosis was severe was sketchy. Many patients had angina as their symptom and 46–75% of these patients also needed repeat CABG at the time of late AVR.4

• There was very little or no documentation of the patients' clinical condition at time of initial CABG and at the time of late AVR. At the time of late AVR some of the studies stated that many …