Sotirios N. Prapas, M.D., Ph.D, F.E.C.T.S.
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1 CORONARY ARTERY REVASCULARIZATION WITH MILD AORTIC STENOSIS: STRATEGIES OF TREATMENT 9 th ANNUAL MEETING OF THE EAB SOCIETY, Pravets, Bulgaria, 2012 Sotirios N. Prapas, M.D., Ph.D, F.E.C.T.S. Director of Cardiac Surgery Department Henry Dunant Hospital, Athens, Greece
2 ACC / AHA GUIDELINES CAD + SEVERE AS CABG +AVR (Mean > 50 mm Hg) CAD + MODERATE AS CABG +AVR (II a) (Mean > mm Hg) CAD + MILD AS CABG +AVR (II b) (Mean < 30 mm Hg)
3 ISSUES TO BE DISCUSSED 1 Incremental risk of concomitant AVR at the time of CABG 2 The likelihood that A.S. will progress requiring reoperative AVR
4 ISSUES TO BE DISCUSSED 3 The mortality of reoperations for AVR 4 The burden of prosthetic valve disease: Risk of endocarditis Early degeneration Anticoagulant related complications
5 RISK OF CONCOMITANT AVR STS Mortality CABG 2 3 % CABG + AVR 6 7 % # Calcified Ascending Aorta # Renal Dysfunction # COPD) # In dialysis patients, more than 30% # 1 year survival 59% # 5 years survival 21%
6 THE MORTALITY OF REOPERATION STS Mortality AVR after prior CABG 12-23,5%
7 FREEDOM FROM AV REOPERATION B. Sareyyupoglu et al, Ann Thorac Surg 2009;88:
8 REOPERATION RATE PER TIME B. Sareyyupoglu et al, Ann Thorac Surg 2009;88:
9 THE PROSTHETIC VALVE DISEASE Anticoagulant-related haemorrhages 2-4% per year Deterioration of bioprosthetic valve after years Possibility of endocarditis
10 THE PROSTHETIC VALVE DISEASE B. Sareyyupoglu et al, Ann Thorac Surg 2009;88:
11 RATE OF PROGRESSION Initial gradient in patients with isolated CABG J. Tam et al, Ann Thorac Surg 1998;65:
12 RATE OF PROGRESSION FINDINGS A) Calcified AV with initial gradient 0 mm Hg Progression gradient: 3,9 mm Hg per year B) Calcified AV with initial gradient 25 mm Hg Progression gradient: 7,1 mm Hg per year Initial gradient in patients with isolated CABG S.W. Davis et al, Eur Heart J, 1991;12:10 14
13 RATE OF PROGRESSION Severity of Valvular Calcification J. Tam et al, Ann Thorac Surg 1998;65:
14 RATE OF PROGRESSION A) Degenerative (more rapid progression) B) Rheumatic C) Related to Congenital Deformation Pathology of Valvular Stenosis J.J Collins et al, J Cardiac Surgery, 1994;9:145 7
15 RATE OF PROGRESSION A) LV Hypertrophy B) Systematic Atheromatosous Disease C) Elderly # Need for medical treatment Comorbidities which lead to more rapid progression W.T. Smith et al, J Am Coll Cardio, 2004;44:1241 7
16 RATE OF PROGRESSION D) Chronic Renal Failure - Haemodialysis HIGHLY PROGRESSION INCREASED MORTALITY (TOWARDS 39%) LOWER SURVIVAL RATE (1 year: 59% - 5 years: 21%) Comorbidities which lead to more rapid progression B. Sareyyupoglu et al, Ann Thorac Surg 2009;88:
17 OUTCOMES REOPERATION FREE SURVIVAL B. Sareyyupoglu et al, Ann Thorac Surg 2009;88:
18 OUTCOMES ALL CAUSE MORTALITY 107 CABG patients VS 209 CABG + AVR patients # 10 years survival, Mayo Clinic, 2009
19 If the decision favors combined surgery...
20 A) CABG + MILD AORTIC STENOSIS IMPACT OF MULTIPLE GRAFTS B) 86 CABG x 1 (CAD 1,76 ± 1,1) 81 CABG x 2 (CAD 2,90 ± 1,3) 66 CABG x3 (CAD 3,73 ± 1,2) C) Mean Age 75 ± 10,1, 73 ± 11, 72 ± 10 D) Lima to LAD: 94%, 92%, 94% Multiple VS Incomplete Revascularization E) Mortality: 9,3%, 11,1%, 7,6% F) Predictors: Age >65, E.F. <30, Urgency, COPD, NYHA III or IV K.J. Kobayashi et al, Ann Thorac Surg 2007;83:969 78
21 IMPACT OF MULTIPLE GRAFTS Multiple VS Incomplete Revascularization K.J. Kobayashi et al, Ann Thorac Surg 2007;83:969 78
22 IMPACT OF MULTIPLE GRAFTS Complete VS Incomplete Revascularization K.J. Kobayashi et al, Ann Thorac Surg 2007;83:969 78
23 If the decision favors combined surgery...
24 EFFICACY OF IMA IMA to LAD favors 5 YEARS SURVIVAL 63 ± 7 % (IMA group) 42 ± 5 % (SVG group) S.Gall et al, Ann Thorac Surg 2000;69:
25 EFFICACY OF IMA IMA to LAD favors 5 YEARS SURVIVAL S.Gall et al, Ann Thorac Surg 2000;69:
26 EFFICACY OF IMA Open LAD or LIMA to LAD have similar survival and proven superior than SVG to LAD S.Gall et al, Ann Thorac Surg 2000;69:
27 If the decision favors combined surgery...
28 CHOICE OF VALVE ACCORDING TO AGE
29 B-AVR versus M-AVR B-AVR versus predicted survival M-AVR versus predicted survival C. Akins et al, Ann Thorac Surg 2002;74:
30 If the decision favors combined surgery...
31 WHICH TECHNIQUE? 1 CLASSICAL CABG + AVR 2 OPCAB + AVR
32 WHICH TECHNIQUE? 3 OPCAB + TAVI (transapical) 4 PCI + TAVI (transcutaneous)
33 1 CLASSICAL CABG + AVR Classical method extends the CPB and aortic X-clamb time
34 2 CABG + MILD AORTIC STENOSIS OPCAB + AVR Henry Dunant Hospital
35 OPCAB + AVR
36 OPCAB + AVR
37 OPCAB + AVR Henry Dunant Hospital
38 OPCAB + AVR Henry Dunant Hospital
39 OPCAB + AVR Henry Dunant Hospital
40 OPCAB + AVR Henry Dunant Hospital
41 Henry Dunant Hospital CABG + MILD AORTIC STENOSIS OPCAB + AVR PATIENTS (4 REDOS) Mean Age 72 Years Bioprosthetic: 97 Metalic:59
42 Henry Dunant Hospital CABG + MILD AORTIC STENOSIS OPCAB + AVR 30 days Mortality 3 / 156 (1,9%) 10 Years Survival 82 %
43 3 OPCAB + TAVI (transapical)
44 4 PCI + TAVI (transcutaneous)
45 CONCLUSIONS The decision of simultaneous treatment of mild aortic stenosis, in patients undergoing coronary revascularization, must be made, based on the evaluation of every case. Both groups of patients, the one of isolated CABG and the one of combined operation with AVR, as proven, have similar long term survival. But, a great percentage of patients from the first group, must undergo a redo operation, basically AVR one, because of progression of aortic stenosis.
46 CONCLUSIONS The decision of combined operation must be made based on the additional risk factors for every individual patient, as well as the estimated, for every case, progression of the aortic stenosis. Patients prone to faster progression of the stenosis, are those with an atheromatosous aortic stenosis, as well as those who are on chronic dialysis. Consequently, simultaneous AVR must be performed basically in patients with renal insufficiency -despite the high risk-, and in patients with degenerative calcified stenosis, who have a relevant higher gradient and higher calcification rate, especially if they are young.
47 CONCLUSIONS The use of IMA for LAD revascularization is beneficial for the long term cumulative survival. The use of bioprosthetic valves is related to better long term cumulative survival, compared with predective for age-and-gender-matched controls. Therefore, in combined operation of CABG + AVR, the use of bioprosthetic valve, should be considered even for younger patients.
48 CONCLUSIONS In combined surgery, the most important of all, in all groups of patients is the revascularization of the LAD using the LIMA. Even incomplete revascularization Is proven beneficial for older patients. OPCABG combined with AVR, as performed in our Department, in Henry Dunant Hospital, proves to be beneficial, while the perioperative mortality is lower that the STS mortality predicted.
49 CONCLUSIONS PCI + TAVI transcutaneous, applied in high risk patients has similar cumulative survival compared to the combined surgery and ranges around 12%. The use of Transapical TAVI in patients who previously underwent a ByPass operation has similar risk compared to the use of TAVI in patients with aortic stenosis, diagnosed for the first time.
50 CONCLUSIONS The final decision for a combined CABG + AVR operation must be taken according to the parameters related to each individual patient and to the Surgeon s experience. Ideally, this decision must be taken by a HEART TEAM.
51 Благодаря Thank you
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