Coronary Atherosclerosis in Valvular Heart Disease

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1 Coronary Atherosclerosis in Valvular Heart Disease Jerome Lacy, M.D., Robert Goodin, M.D., Daniel McMartin, M.D., Ronald Masden, M.D., and Nancy Flowers, M.D. ABSTRACT To evaluate the usefulness of routine coronary arteriography in patients undergoing cardiac catheterization for the evaluation of valvular heart disease, we performed coronary arteriographic studies routinely in a series of 21 patients primarily catheterized for such evaluation. Coronary artery obstructive lesions in excess of 5% of the lumen were present in 45 of the 21 patients. In 18 of the 45 there was no history of chest pain. Three of the 18 had three vessels involved while 2 had two vessels involved. A total of 27 patients (1.4%) had luminal obstruction greater than 7%, and 9 of these had no pain. In 5 of the 21 patients, classic angina pectoris existed in the absence of radiographically significant disease. Severe coronary disease was found to coexist with hemodynamically severe valvular heart disease and was not predictable noninvasively. The need for routine coronary arteriography in patients undergoing cardiac catheterization because of valvular heart disease has received conflicting reports in the literature. Several investigators have suggested that all patients over 4 years of age have coronary arteriography as part of their preoperative catheterization and that bypass surgery be considered if significant coronary disease exists [4,71. Other reports have stated that coronary arteriography is an unnecessary procedure unless the patient with valvular heart disease also has angina pectoris [l, 21. Concomitant coronary artery disease has been implicated in the operative and postoperative morbidity and mortality of patients undergoing valve replacement, and identification of this group of patients is desirable [71. If such a group is predictable by clinical judgment alone, From the Section of Cardiology, Department of Medicine, University of Louisville School of Medicine, Louisville, KY. Accepted for publication Nov 9, Address reprint requests to Dr. Flowers, Section of Cardiology, University of Louisville School of Medicine, 2 E Chestnut St, Louisville, KY 422. the added risk and cost of coronary arteriography could be avoided in such patients. The purpose of this study was to determine the incidence of coronary artery disease in our patients with valvular heart disease and to evaluate the accuracy with which it can be predicted by noninvasive clinical means alone. Further, we wished to test the assertions made by others that significant coronary atherosclerosis would necessarily be revealed by hemodynamically significant valvular heart disease and that coronary arteriography is thus not indicated in such patients in the absence of angina pectoris [l, 21. Materials and Methods During a period of two and onehalf years, coronary arteriography was carried out in 21 adult patients undergoing cardiac catheterization for evaluation of valvular heart disease. The patients were studied without regard to factors that might suggest coronary artery disease or a predisposition to it. The group included 14 women with a mean age of 49 years and 97 men with a mean age of 5 years. The age range for the group was 18 to 74 years. Historical evaluation included determination of functional cardiac class according to the New York Heart Association classification, the cataloging of risk factors for coronary disease, and detailed inquiry into the presence and character of chest pain. Physical examination was further supported by phonocardiograms and external pressure pulse recording in most patients, and all patients had electrocardiograms and chest roentgenograms. Catheterization data included left ventriculography and coronary arteriography in all patients, and pulmonary arteriography in most patients. Hemodynamic measurements from both the right and left cardiac chambers were recorded. Patients were classified as to age, sex, type of valve disease, and the presence and severity of coronary artery disease. Severity was judged in 429

2 4 The Annals of Thoracic Surgery Vol 2 No 5 May 1977 terms of the estimated percentage of luminal obstruction (based on multiple views) and number of vessels involved. Patient groups identified were those without chest pain, those with pain atypical for angina pectoris, and those with typical angina. To be designated as having typical angina pectoris the patients had to have anterior ch.est, neck, or arm pain with at least one of the lollowing: precipitation of pain by exertion, emotional stress, or exposure to cold, or consistent relief of pain by rest or nitroglycerin. Anterior chest pain without the specified characteristics was considered pain atypical for angina pectoris. Results From the total population of 21 patients with valvular heart disease, 8 (41%) were found to have coronary artery disease, ranging from luminal irregularity of a single vessel to complete occlusion of two major vessels. Fortyfive patients (22%) had what was termed radiographically significant coronary disease with at least 5 / obstruction in one or more vessels, and 27 patients (1%) had lesions greater than 7%. There were 19 women and 26 men with a mean age of 57 years. The occurrence of radiographically significant coronary disease was 27% for men and IS% for women (Fig 1). Considerations of 4ge The frequency of coronary disease rose with increasing age. The only patient below the age of 4 who had significant disease was a 9yearold woman with singlevessel disease whose only risk factor was cigarette smoking (Fig 2). Considerations of Valvular Abnormalities The severity and distribution of coronary artery lesions in patients with valve abnormalities are listed in Table 1. MITRAL STENOSIS. The study included 67 patients (49 women and 18 men) in whom mitral stenosis was the predominant lesion. There were 21 patients.with coronary artery disease, and 1 (19O/) had significant obstructing lesions; this subgroup was made up of 1 female and male patients with a mean age of 54 years (Fig ). One patient had threevessel disease, 6 1 a (u I fn I c MALE 2 2% FEMALE Fig 1. Coronary artery diseuse (CAD) in patients with valvular disease. had twovessel disease, and 6 had onevessel disease. Three patients were in Functional Class 11, 9 were in Class 111, and 1 was in Class IV. MITRAL REGURGITATION. Thirtythree patients (19 women and 14 men) had mitral regurgitation as the predominant lesion. Twelve patients had coronary artery disease, with 6 (18%) having significant disease; this subgroup included 2 women and 4 men with a mean age of 61. Two patients had threevessel disease, 1 had twovessel disease, and had onevessel disease. Five patients were in Class I11 or IVwith + to 4+ regurgitation. One patient had the click murmur syndrome with 2+ regurgitation. AORTIC STENOSIS. The predominant lesion was aortic stenosis in 56 patients (17 women and 9 men) who were studied. Thirtythree had coronary artery disease, and 12 (21%) had significant obstructing lesions. The mean age was 6 for the 8 men and 4 women making up this subgroup. Two patients had threevessel disease, had twovessel disease, and 7 had singlevessel disease. Gradients across the aortic valve ranged from 58 to 12 mm Hg except for 1 patient with a gradient of 22 mm Hg and another in whom we were unable to cross the valve. Seven patients were in Class 111, 1 was in Class IV, and 1 was in Class 11.

3 41 Lacy et al: Coronary Atherosclerosis in Valvular Heart Disease n 4.2% 19.6% 21.1% 41% 4% AGE ~ Fig2. Age and sexdistribution. (CAD= coronary artery disease.) AORTIC REGURGITATION. Of the patients (11 women and 19 men) who had predominantly aortic regurgitation, 11 had coronary artery disease, with 9 of these (%) having significant obstructing lesions. This subgroup consisted of 1 woman and 8 men with a mean age of 56. Two patients had threevessel disease, 2 had twovessel disease, and 5 had singlevessel disease. Three patients were in Class 11,l was in Class IV, and the remainder were in Class 111. PROSTHETIC VALVES. Fifteen patients (8 women and 7 men) were studied for evaluation of prosthetic valve dysfunction. Six had coronary artery disease, 5 of whom had significant disease. This subgroup included 2 women and men with a mean age of 48. Three patients had twovessel disease and 2 had singlevessel disease. All patients were in Class I11 or IV. Considerations of Pain No history of chest pain could be elicited in 18 (4%) of 45 patients considered to have significant coronary disease. Fourteen patients (1%) had some type of chest pain considered atypical Table 1. Severity and Distribution of Coronary Artery Lesions by Valve Abnormality Involvement and Degree MS MR AS AR P. Valves Total No. of diseased vessels Total Obstruction 2 9% % % Total MS = mitral stenosis; MR = mitral regurgitation; AS = aortic stenosis; AR = aortic regurgitation;. ' I valves = prosthetic valve dysfunction.

4 42 The Annals of Thoracic Surgery VoI 2 No 5 May 1977 Normal UCbO 1 Y FEMALE MALE I n c 8 a I 4 L.' + w 19.4% 18.2% 214% %.% MS M I? AS AR PV Fig. Type of valve disease and coronary artery disease (CAD). (MS=: mitralstenosis; MR= mitral regurgitation; AS= aortic stenosis; AR = aortic regurgitation; PV = prosthetic valve dysfunction.) 2 No Atypical Typical Pain Pain Pain Fig4. Symptoms of pain in patients with coronary artery disease (CAD). for angina pectoris, and 1 patients (29%) were thought to have chest pain typical for angina pectoris (Fig 4). NO PAIN. In the total population of 21 patients, 9 gave no history of chest pains; 18 (19'/) of these patients had asymptomatic significant coronary disease. There were 1 women and 8 men with a mean age of 57 and 62, respectively. This subgroup included 5 patients with mitral stenosis (1lo/o), with aortic stenosis (6.7%), 4 with imitral regurgitation (8.9%), 4 with aortic regurgitation (8.9%), and 2 evaluated for valve dysfunction (4.4%). Three of the patients had threevessel disease, 2 had twovessel disease, and 1 had singlevessel disease. Nine patients had obstructing lesions greater than 7% (Fig 5, Table 2). ATYPICAL PAIN. Sixty patients in the series of 21 had atypical chest pain, and 14 (2%) were found to have significant coronary artery disease. There were 6 women and 8 men with a mean age of 55 This subgroup included 5 patients with mitral stenosis (11O/), 2 with aortic stenosis (4.4%:1, 1 with mitral regurgitation (2.2%), 4 with aortic regurgitation (8.97), and 2 evaluated for valve dysfunction (4.4%). One individual had threevessel disease, 8 had two N (1 6 I w 5 n I 4 I a I 2 NORMAL CAD 19.% 2. % 27.1 % No Atypical Typical Pain Pain Pain Fig5. Symptoms of pain and coronary artery disease (CAD) in totalgroup with valvular heart disease.

5 4 Lacy et al: Coronary Atherosclerosis in Valvular Heart Disease Table 2. Distribution and Severity of Coronary Artery Lesions by Type of Pain Involvement No Atypical Typical and Degree Pain Pain Pain Total No. of diseased vessels 2 1 Total Obstruction 9% 79% 57 /o Total vessel disease, and 5 had singlevessel disease (see Fig 5, Table 2). TYPICAL PAIN. Of the 21 patients studied, 48 gave a history of pain considered typical for angina pectoris. Thirteen (27'/) of them had significant coronary disease. There were women with a mean age of 59 and 1 men with a mean age of 54. This subgroup consisted of patients with mitral stenosis (6.7%), 7 with aortic stenosis (l6%), 1 with mitral regurgitation (2.2%), 1 with aortic regurgitation (2.2%), and 1 evaluated for valve dysfunction (2.2%). Three patients had threevessel disease, 5 had twovessel disease, and 5 had singlevessel disease. Eleven patients were found to have luminal obstruction greater than 9 / (see Fig5, Table 2). ANGINA PECTORIS AND NORMAL CORONARY ARTERIES. There were 5 patients (17%) in the total group of 21 individuals studied who had classic angina pectoris but did not have significant coronary artery disease. Eighteen (8.9%) of these patients had completely normal coronary anatomy. There were 2 patients with aortic stenosis (17 men and 6 women), 5 with mitral stenosis (4 women and 1 man), with aortic regurgitation (2 men and 1 woman), and 2 evaluated for prosthesis dysfunction (2 men). The mean age was 54.8 years in the men and 52 years in the women (see Fig 5). Other Relevant Considerations ELECTROCARDIOGRAM. Only 5 of the 45 patients with significant coronary artery disease showed Q waves greater than msec in the electrocardiogram. Other findings included nonspecific ST and T abnormalities, ventricular enlargement, and rhythm disturbances, mainly atrial fibrillation or premature ventricular beats. COMPLICATIONS OF ARTERIOGRAPHY. There were no deaths, arterial thromboses, or acute infarctions. One patient developed ventricular fibrillation on injection of the right coronary artery and was successfully defibrillated without sequelae. The patient was 7 years old and had severe aortic stenosis and a % proximal lesion in the right coronary artery. RISK FACTORS. Risk factors for coronary artery disease were found with equal frequency in patients with and without coronary disease; risk factors were no more common in patients with typical pain than in those without pain. Comment The 22% of our patients who were shown to have coronary artery disease when evaluated for valvular heart disease represent a sizable population. Further, the 27 patients with luminal obstruction in excess of 7 / represent 1.4% of the total population studied for valvular heart disease. In a recent arteriographic study by Kasparian and coworkers [61, 2% of 16 patients had coronary artery disease. In a recent postmortem series of patients with rheumatic valvular disease, Coleman and Soloff [] reported coincident coronary disease in 1%. Investigations of patients with aortic stenosis by coronary arteriography have shown the incidence of significant coronary artery disease to be as high as 56% [5, 81. In our study, patients with mitral stenosis, mitral regurgitation, and aortic stenosis showed a similar incidence of coronary disease. Patients with aortic regurgitation showed a higher incidence even though their mean age of 56 years was lower than that of the group with mitral regurgitation and aortic stenosis. However, the group with aortic regurgitation contained a higher percentage of men than the other groups (see Fig ). Otherwise, a suggestion of sex difference was clearly manifest only in the seventh decade (see Fig 2). A 9yearold woman with singlevessel disease was the only patient below age 4 found to have coronary disease.

6 44 The Annals of Thoracic Surgery Vol 2 No 5 May 1977 In those patients studied with no history of chest pain, 19% were found to have significant coronary disease. A similar incidence has been reported by others [6]. In contrast, an investigation by Bonchek and associates [2] of 1 patients having a valve replaced reported no patients with significant asymptomatic coronary disease, and they postulated that the increased myocardial work imposed by chronic valvular disease would make any significant comronary obstruction symptomatic. As pointed out by Bonchek, patients with pure mitral stenosis usually do not have abnormal left ventricubr function and conceivably could be more likely to have asymptomatic coronary disease. However, patients without pain in our series included individuals with mitral regurgitation and aortic valve disease as well as mitral stenosis. Only 27% of thee patients with typical angina had significant coronary disease, but a large number of patients with aortic stenosis were in this group. However, 71% of our patients with coronary disease did not have typical angina or a history of previoiis myocardial infarction, thus making the historical diagnosis of atherosclerotic heart disease somewhat insensitive in our patient population. The severity of coronary disease when related to symptoms of chest pain did not show a close correlation. Threevessel disease occurred with equal frequency in patients with and without typical angina, but singlevessel disease was more common in the group without pain. Obstructive lesions greater than 7% occurred in 11 patients with typical angina and 9 patients without pain. Lesions greater than 9% were more common in individuals with typical pain, and lesions less than 7% were more frequent in patients without pain (see Table 2). Several factors may have contributed to the inadequacy of noninvasive prediction of coronary artery disease. Patients who have catheterization done because of valvular heart disease commonly are taking digitalis and have abnormal resting ECGs and functional impairment severe encough either to preclude exercise stress testing or to make its interpretation difficult. The presence of Q waves of greater than msec occurred in only a small number of our patients, and in only 2 patients without typical angina. Also, risk factors for coronary atherosclerosis were found with equal frequency in patients with and without coronary disease. The risk of coronary arteriography must be considered; the risk varies according to the catheterization laboratory doing this procedure. A very low complication rate should be expected in those centers doing a large number of procedures. In our laboratory all complications, including vascular thromboses, lifethreatening arrhythmias, and myocardial infarctions, occur in less than 1%. Mortality is less than.2%, and there have been no deaths associated with the last consecutive 1,1 catheterizations, all but 1 of which included coronary arteriography. Within the period of this study there were 15 mitral valve replacements with one or more concomitant saphenous vein bypass graft procedures performed. There were no early deaths, nor have there been any late deaths as of this writing. When aortic valve replacement was done at the time of coronary bypass surgery, however, 4 deaths occurred in 12 patients so treated. This mortality is compared with a perioperative, inhospital mortality of % for aortic valve replacement alone. In both groups the indications for bypass surgery were either severe, medically unresponsive angina pectoris or lesions 7% or greater (usually subtotal occlusions) in locations considered to be critical, such as the left main coronary artery or the very proximal portion of its left anterior descending branch. In conclusion, we found coronary disease of radiological significance to exist in an asymptomatic form in many patients with symptomatic, hemodynamically severe valvular heart disease, as well as in patients with chest pain. In spite of carefully done precatheterization evaluations, we were not able to detect such disease with the degree of reliability that is desirable in an individual patient. We believe insufficient time has elapsed for the impact of specific delineation of coronary disease to be evaluated as an important element in determining appropriate medical and surgical management, and therefore the ultimate outcome, in these patients with valvular heart disease. We do believe that if data obtained through ar

7 45 Lacy et al: Coronary Atherosclerosis in Valvular Heart Disease teriography emerge as important determinants of the course of action, our study supports the thesis that they can be obtained with minimal risk; they cannot be reliably deduced or extrapolated by noninvasive means. With these considerations, in laboratories with comparable morbidity and mortality to our own, we believe the results of coronary arteriography should be a routine part of the presurgical data base. References 1. Basta LL, Raines RD, Najjar S, et al: Clinical, hemodynamic and angiographic correlates of angina pectoris in severe aortic valve disease (abstract). Clin Res 2151, Bonchek LI, Anderson RP, Rosch J: Should coronary arteriography be performed routinely before valve replacement? Am J Cardiol 1:462, 197. Coleman EH, Soloff LA: Incidence of significant coronary artery disease in rheumatic valvular heart disease. Am J Cardiol 25:41, Flemma RJ, Johnson WD, Lepley D, et al: Simultaneous valve replacement and aortatocoronary saphenous vein bypass. Ann Thorac Surg 12:16, Hancock EW: Clinical assessment of coronary artery disease in patients with aortic stenosis (abstract). Am J Cardiol 5:142, Kasparian H, Duca PR, Goodman S, et al: The diagnosis and management of obstructive coronary disease in patients with significant chronic valvular disease. Cardiovasc Clin 5:7, Linhart JW, Wheat MW: Myocardial dysfunction following aortic valve replacement: the significance of coronary artery disease. J Thorac Cardiovasc Surg 54:259, Moraski RE, Russell RO, Rackley CE: Aortic stenosis, angina pectoris and coronary artery disease (abstract). Circulation 49,5O:Suppl :7, 1974