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ORIGINAL ARTICLE

Does the coronary disease increase the hospital mortality in patients with aortic stenosis undergoing valve replacement?

José de Lima Oliveira JúniorI; Alfredo Inácio FiorelliII; Ronaldo Honorato Barros SantosIII; Pablo Alberto Maria PomerantzeffIV; Luís Alberto de Oliveira DallanV; Noedir Antonio Groppo StolfVI

DOI: 10.1590/S0102-76382009000500005

INTRODUCTION

For holders of aortic stenosis (AoS), the start of symptoms represents a critical point, by reducing life expectancy. In the 1950's, Kirklin et al. acquired unsatisfactory results with the surgical treatment of the aortic valve [1]. In the following decades, the aortic valve substitution (AVS) became an efficient therapeutic alternative [2], achieving better results than those in drug or percutaneous treatments [3]. The profile of the patients submitted to AVS has changed over the last few years, with an increase in the proportion of high risk patients [4,5]. The surgical treatment combined of the coronary artery disease (CAD) + AoS represents about 15% of the cardiac operations currently performed in the United States [6]. In the early 1990's, Lytle et al. [7], revising the operative results of the Cleveland Clinic Foundation, observed that the isolated surgical approach in the aortic valve had a negative impact in the operative mortality of patients holding valvar lesion combined to CAD. More recently, Florath et al. [8] reported a significant reduction in operative mortality of patients submitted to the combined procedure.

This study aims to evaluate the influence of CAD, in hospital mortality of patients holding AoS, submitted to AVS isolated or combined to myocardial revascularization (MR).


METHODS

Perspective observational study (Coorte), involving two consecutive groups of patients, holders of AoS, associated or not to critical CAD, submitted to AVS, combined or not to RM, operated at the InCor-HC-FMUSP, between 2001 and 2006. Not including: patients submitted to any other combined surgical procedure; operated for acute endocarditis; holders of AoS associated to aortic insufficiency; submitted to any other previous heart surgery, other than the conservative surgical treatment of AoS; with more than one previous aortic valve operation; previous AVS, urgency or emergency. The patients were divided in two groups:

  • Group G1: holders of AoS submitted to isolated AVS, with associated CAD (G1A), without associated CAD (G1B);
  • Group G2 holders of AoS, associated to critical CAD, submitted to AVS combined to complete MR (G2A) or incomplete MR (G2B).


  • In the G1, the average age was 53.9 ±16.2 years, 47 (10.5%) patients presented critical associated CAD, 163 (36.4%) were female. In the GII, the average age was 67.3 ± 9.5 years, 42 (25.1%) were female. The frequency of preoperative and intra-operative data is described in Tables 1 and 2.






    For the statistical analysis in the group composition evaluation, the following tests were used: qui-square test, t of Student and exact test of Fisher, followed by multivariate analysis (logistical regression model). Admiting statistical significance level of P < 0.05. The Hosmer-Lemeshow test was applied to test the model adjustment. The hospital deaths were considered routinely.


    RESULTS

    The patients submitted to isolated AVS (G1), the hospital mortality was 14.3%, being 57.8% due to cardiac causes and 42.2% due to non-cardiac causes. The distribution of hospital mortality of G1, according to perioperative data, is described in Tables 3 and 4. In G1B, the hospital mortality was 14.5%, in G1A, 12.8%, being 6.3% in patients with uniarterial disease, 33.3% in two arteries compromised, with no deaths in the three arteries compromised. In G1, serum creatinine e"1.5 mg/dL (P = 0.001), extracorporeal circulation time higher than 90 minutes (P = 0.022) and aortic clamping higher than 60 (P = 0.010), presence of associated CAD, in at least two arteries (P = 0.016) influenced hospital mortality (Table 5).








    The patients submitted to AVS combined with MR (G2), the hospital mortality was 17.4%, being 10.4% in the one artery compromised, 13.6% in the two arteries compromised and 24.0% in the three arteries compromised. The distribution of hospital mortality in GII, according to perioperative data, is described in Tables 6 and 7. In G2A, the hospital mortality was 16.1% and 20.9% in G2B. In G2, female (P = 0.037), extracorporeal circulation time higher than 180 minutes (P = 0.030), serum creatinine > 1.5 mg/dL, cerebrovascular accident antecedent (P = 0.041) and performance of more than two distal anastomosis (P = 0.031) influenced hospital mortality (Table 8).








    DISCUSSION

    The aortic valve substitution is currently the most performed valvar operation in the United States [9]. In G1, 10.5% presented critical associated CAD (G1A), that was not approached, in this subgroup, the proportion of one artery compromised patients is high, 68.1%, but the proportion of two arteries compromised or three arteries compromised is small, 25.5% and 6.4% respectively, which suggests higher tendency of being a combined form, patients with more extensive coronary damage. In G2, it was observed a more homogeneous distribution in the proportions of coronary damage, 45% of three arteries compromised patients, 26.3% of two arteries compromised and 28.7% one artery compromised. In this study it was also observed the proportion of two arteries and three arteries compromised patients in G2 (71.3%) was higher than in G1A (31.9%), confirming higher probability of performing the combined surgery in patients with more extensive coronary disease.

    In G1, it was observed that the presence of more than one coronary artery critical lesion, determined risk of hospital death 4.99 times higher than in patients without this association. Lytle et al. [10,11], revising data in the Cleveland Clinics, between 1972 and 1986, observed that out of 1689 patients submitted to isolated AVS, 181 presented critical associated CAD and in this subgroup, the operative mortality was two times higher than in the pacientes without associated CAD. In this study, the CAD was not only analyzed as a binary variable but also stratified according the number of coronary arteries with critical lesion, thus, it was observed that the "statistic behavior" of the one artery compromised patients was similar to the patients without associated CAD, which explains what was observed when G1 was stratified, due to the presence of critical associated CAD (binary form), hospital mortality in G1A was similar to G1B, noting that the preoperative and intraoperative data analyzed was rather similar in both groups. The absence of death among three arteries compromised patients, the proximity of "statistical behavior" of the uniarterial patients (part of group GIA) compared to the patients without critical associated coronary atherosclerotic lesion (group GIB) and the high proportion of one artery compromised patients in GIA approximated the hospital mortality of the patients without associated CAD or one artery compromised.

    In GII, the hospital mortality increased according to the number of arteries compromised, being 10.4% in one artery compromised, 13.6% in two arteries compromised and 24.0% in three arteries compromised, with no statistical significance. The hospital mortality was 24.0% in three arteries compromised and 12.0% in one arteries / two arteries compromised, with statistical significance only in the univariated analysis. The influence of the extension of MR combined to AVS is also controversial in literature. The MR anatomically complete could determine an earlier functional recovery of the ventricle and decrease in the occurrence of cardiovascular events in the mild and long term, although with higher time of ECC and aortic clamping, higher manipulation of the aorta, which could increase morbidity [12]. In this study, as we analyzed holders of AoS, CAD associated or not, having the valvar lesion as the main diagnostic criterion and surgery referral, we used the anatomical criterion in order to define the extension MR performed, which had no influence in hospital mortality, similar results to those described by Cosgrove et al. [13] and Lavee et al. [14]. On the other hand, the patients submitted to MR with more than three distal anastomoses, the risk of hospital death was 6.54 times higher, unlike the one described by Cosgrove et al. [13], to which the performance of a higher number of grafts would work as a "protection", reducing mortality. It is worth noting that correlating the stratification of GII, according to the extension of MR, with the stratification, according the number of coronary arteries with critical lesion, it was observed that hospital mortality, in the one artery or two arteries compromised, submitted to complete MR was 12.1%, in the three arteries compromised submitted to complete MR was 23.8%, in the two arteries submitted to incomplete MR was 11.1% and in the three arteries compromised submitted to incomplete MR was 23.5%.

    It can be concluded that:

    1. In patients of aortic stenosis submitted to isolate valvar substitution, the presence of critical associated CAD, in at least two arteries, increased hospital mortality;

    2. In patients of aortic stenosis, with critical associated CAD, submitted to AVS combined with MR, the number of coronary arteries with critical atherosclerotic lesion had no influence, as well as the performance of complete or incomplete MR, but the performance of more than three distal anastomoses combined to AVS increased hospital mortality.


    REFERENCES

    1. Ellis FH Jr, Kirklin JW. Aortic stenosis. Surg Clin North Am. 1955;1029-34. [MedLine]

    2. Kon ND, Westaby S, Amarasena N, Pillai R, Cordell AR. Comparison of implantation techniques using freestyle stentless porcine aortic valve. Ann Thorac Surg. 1995;59(4):857-62. [MedLine]

    3. Dancy M, Dawkins K, Ward D. Ballon dilatation of the aortic valve: limited success and early restenosis. Br Heart J. 1988;60(3):236-9. [MedLine]

    4. Thourani VH, Weintraub WS, Craver JM, Jones EL, Mahoney EM, Guyton RA. Ten-year trends in heart valve replacement operations. Ann Thorac Surg. 2000;70(2):448-55. [MedLine]

    5. Stewart BF, Siscovick D, Lind BK, Gardin JM, Gottdiener JS, Smith VE, et al. Clinical factors associated with calcific aortic valve disease. Cardiovascular Health Study. J Am Coll Cardiol. 1997; 29 (3):630-4. [MedLine]

    6. O'keefe JH Jr, Vliestra RE, Bailey KR, Holmes DR Jr. Natural history of candidates for ballon aortic valvuloplasty. Mayo Clinic Proc. 1987;62(11):986-91.

    7. Kaul KT, al Khadimi R, Sharif H, Ramsdale DR. Results of combined valve replacement and myocardial revascularization. Relation to method of myocardial protection. J Cardiovasc Surg. 1989;30(3):322-7.

    8. Florath I, Albert A, Hassanein W, Arnrich B, Rosendahl U, Ennker IC, et al. Current determinants of 30-day and 3-month mortality in over 2000 aortic valve replacements: Impact of routine laboratory parameters. Eur J Cardiothorac Surg. 2006;30(5):716-21. [MedLine]

    9. Edmunds LH Jr, Clark RE, Cohn LH, Grunkemeier GL, Miller DC, Weisel RD. Guidelines for reporting morbidity and mortality after cardiac valvular operations. Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity of The American Association for Thoracic Surgery and The Society of Thoracic Surgeons. J Thorac Cardiovasc Surg. 1996;112(3):708-11. [MedLine]

    10. Lytle BW. Impact of coronary artery disease on valvular heart surgery. Cardiol Clin. 1991;9(2):301-14. [MedLine]

    11. Fresenius medical care. Accessed in 21/01/2009. Avaliable from: URL: http://www.fmc-ag.com.br

    12. Bell MR, Gersh BJ, Schaff HV, Holmes DR Jr, Fisher LD, Alderman EL, et al. Effect of completeness of revascularization on long-term outcome of patients with three-vessel disease undergoing coronary artery bypass surgery. A report from the Coronary Artery Surgery Study (CASS) Registry. Circulation. 1992;86(2):446-57. [MedLine]

    13. Cosgrove DM, Loop FD, Lytle BW, Baillot R, Gill CC, Golding LA, et al. Primary myocardial revascularization. Trends in surgical mortality. J Thorac Cardiovasc Surg. 1984;88(5 Pt 1):673-84. [MedLine]

    14. Lavee J, Rath S, Tran-Quang-Hoa, Ra'anani P, Ruder A, Modan M, et al. Does complete revascularization by the conventional method truly provide the best possible results? Analysis of results and comparison with revascularization of infarct-prone segments (systematic segmental myocardial revascularization): the Sheba Study. J Thorac Cardiovasc Surg. 1986;92(2):279-90. [MedLine]

    Article receive on Wednesday, June 3, 2009

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