Original article: cardiovascular
Results of bioprosthetic versus mechanical aortic valve replacement performed with concomitant coronary artery bypass grafting

https://doi.org/10.1016/S0003-4975(02)03840-7Get rights and content

Abstract

Background. Concomitant coronary artery disease with aortic valve disease is an established risk factor for diminished late survival. This study evaluated the results of bioprosthetic (BAVR) or mechanical aortic valve replacement (MAVR) performed with coronary artery bypass grafting (CABG).

Methods. From January 1984 through July 1997, combined AVR + CABG was performed in 750 consecutive patients; 469 received BAVR and 281 received MAVR. BAVR recipients were significantly older (mean age, 75 vs 65 years), and had more nonelective operations, congestive heart failure, peripheral vascular disease, preoperative intraaortic balloons, lower cardiac indices, more severe aortic stenosis, less aortic regurgitation, and more extensive coronary artery disease.

Results. Early complications included operative mortality, 32 patients (4.3% total: 3.8% BAVR and 5.0% MAVR); perioperative infarction, 10 (1.3%); and perioperative stroke, 22 (2.9%). Significant multivariable predictors of early mortality were age, perioperative infarction or stroke, nonelective operation, operative year, ventricular hypertrophy, and need for intraaortic balloon. Ten-year actuarial survival was 41.7% for all patients. Predicted survival for age- and gender-matched cohorts from the general population versus observed survival were BAVR, 45% versus 36%; MAVR, 71% versus 48% (survival differences BAVR 9% vs MAVR 23%, p < 0.007). Significant multivariable predictors of late mortality included age, congestive failure, perioperative stroke, extent of coronary disease, peripheral vascular disease, and diabetes. Valve type was not significant. Ten-year actuarial freedom from valve-related complications were (BAVR vs MAVR) structural deterioration, 95% versus 100%, p = NS; thromboembolism, 86% versus 84%, p = NS; anticoagulant bleeding, 93% versus 88%, p < 0.005; reoperation, 98% versus 98%, p = NS.

Conclusions. AVR + CABG has diminished late survival despite the type of prosthesis inserted. Although valve type did not predict late mortality, mechanical AVR was associated with worse survival compared with predicted and more valve-related complications due to anticoagulation requirements.

Section snippets

Patients

A computerized registry of cardiac surgical patients at the Massachusetts General Hospital was used to identify 750 consecutive patients having combined aortic valve replacement and coronary artery bypass grafting from January 1984 through July 1997. Because the principal focus of the study was the long-term consequences of prosthesis selection, the study was closed at that time to allow a follow-up period of at least 2 postoperative years for every patient in the study. Records of 750

Results

Some important demographic and clinical risk factors are listed in Table 1. Bioprosthetic valve recipients were significantly older, had smaller body surface areas, and more peripheral vascular disease.

The 469 bioprostheses implanted in this study included 341 Carpentier-Edwards porcine and 128 Carpentier-Edwards pericardial valves. The 281 mechanical valves implanted in this study included 168 St. Jude Medical, 56 Medtronic-Hall, 45 Starr-Edwards, 11 Bjork-Shiley, and one CarboMedics valves.

Comment

Several published studies have compared the long-term results of the decision to insert a bioprosthetic or mechanical valve in patients who require aortic valve replacement 1, 2, 3, 4, 5, 6, but most of the patients in those studies had isolated valve replacement. Other studies have documented the deleterious impact on late survival of concomitant coronary artery bypass grafting when required in conjunction with aortic valve replacement 7, 8, 9, 10. In 1994, Jones and colleagues documented the

Acknowledgements

This study was supported by a grant from the John F. Welch/GE Fund for Cardiac Surgical Research. The authors wish to acknowledge the assistance of Barbara J. Akins, BSN, and Annetta L. Boisselle, BSN, for their help in data acquisition and management; John B. Newell, former director of the Cardiac Computer Center, Massachusetts General Hospital, for his assistance in the statistical evaluations; and Jerene M. Bitondo, PA-C, for her help with manuscript preparation.

References (22)

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Dr Akins discloses that he has a financial relationship with Medtronic, Inc.

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