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DEPARTMENT OF THORACIC & CARDIOVASCULAR SURGERY ST. PAUL ’ S HOSPITAL

SURGICAL STRATEGRY FOR CABG WITH ASSOCIATED VALVE SURGERY. DEPARTMENT OF THORACIC & CARDIOVASCULAR SURGERY ST. PAUL ’ S HOSPITAL THE CATHOLIC UNIVERSITY OF KOREA CHAN BEOM PARK. STS Database Jan 1992-Dec 2001. AVR. 4.18%. AVR+CABG. 4.26%. MVR. 2.01%. CABG 75.2%. 1.37%. MVR+CABG.

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DEPARTMENT OF THORACIC & CARDIOVASCULAR SURGERY ST. PAUL ’ S HOSPITAL

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  1. SURGICAL STRATEGRY FOR CABG WITH ASSOCIATED VALVE SURGERY DEPARTMENT OF THORACIC & CARDIOVASCULAR SURGERY ST. PAUL’S HOSPITAL THE CATHOLIC UNIVERSITY OF KOREA CHAN BEOM PARK

  2. STS Database Jan 1992-Dec 2001 AVR 4.18% AVR+CABG 4.26% MVR 2.01% CABG 75.2% 1.37% MVR+CABG 0.86% 0.92% AVR+MVR MV Repair 10.7% MV Repair+CABG Other Combinded Procedures. In: Surgery of Coronary artery disease, Wheatley DJ. London: Arnold 2003, 326-33.

  3. 대한흉부외과학회 Database 2001-2005 2340 2176 2055 1968 1700 213 185 123 147 145 [ http://www.ktcs.or.kr/ ]

  4. CABG with Aortic Valve disease

  5. Operative Mortality for AVR with or without CABG –STS Database- 10 AV Replace AV Replace+CABG 8 6 Percent 4 2 0 1994 1995 1996 1997 1998 1999 2000 2001 Procedure year Combinded Procedures. In: Surgery of Coronary artery disease, Wheatley DJ. London: Arnold 2003, 326-33.

  6. Long-term Survival after AVR with CABG Major cardiac event: reoperation, permanent neurologic event, MI, bleeding, endocarditis, hospitalization for CHF, NYHA III/IV Sx, death Lytle BW. JTCS 1988;95:402-14

  7. Survival after AVR with/without CABG Hosp. Mortality 1.0 3.4% No CAD(N=1396) Mean Age 56yrs 0.8 7.9% 60% 0.6 Survival p<0.0001 0.4 39% 0.2 CAD(N=883) Mean Age 67yrs 0.0 20 0 5 10 15 Time (Yrs) Jones EL. ATS 1994;58:378-85

  8. Clinical Factors associated with Calcific Aortic Valve disease *±75th vs 25th percentile. †±10-year increase. ‡±10unit increase. LDLc=low density lipoprotein cholesterol; Lp(a)=lipoprotein(a) Stewart BF. JACC1997;29:630-4

  9. AV Calcification associated with Coronary Atherosclerosis Pohle K. Circulation2001;104:1927-32

  10. Atherosclerotic Changes in Aortic Valves of Hypercholesterolemic Rabbits Aortic Valve-Cholesterol diet Aorta-Cholesterol diet Aorta-Normal diet Aortic Valve-Cholesterol diet

  11. Management of Asx Mild AS during CABG 100 CABG then AVR CABG/AVR 80 P E R C E N T 26±10mmHg 1.05±0.2cm2 53.2±24mmHg 0.73±0.21cm2 60 p = NS 8.9yr 40 61.3±26mmHg 0.69±0.12cm2 20 CABG then AVR CABG with AVR 0 0 1 2 3 4 5 6 7 8 9 10 YEARS Mild AS >1.0cm2 Fiore AC. ATS 1996;61:1693-8

  12. Freedom from AVR(CABG)vs AV Reop(AVR/CABG)in Mild to Moderate AV Disease P=0.0024 3% 24.3% CABG AVR/CABG Mean AS gradient CABG: 25.9±11.2 (14-66) mmHg AVR/CABG: 52.5±18.9 (14-126) mmHg Hochrein J. Am Heart J1999;138:791-7

  13. Survival after Mild/Moderate AVR with CABG AVR-CABG AVR-CABG CABG CABG Mild AS : Mean PG< 30mmHg, and/or Valve area >1.5cm2 Moderate AS : Mean PG≥30mmHg and ≤40mmHg, and/or Valve area >1.0 and ≤1.5cm2 Pereira JJ. Am J Med 2005;118:735-42

  14. Progression of Mild AS in CABG Patients yrs 0 1 2 3 4 5 6 7 8 9 Tom JW. ATS1998;65:1215-9

  15. Predictors of Outcome- Calcification, AV velocity, CAD - No CAD (1,3,5yr) : 98±1%, 86±3%, 74±4% CAD (1,3,5yr) : 94±3%, 63±7%, 40±8% (p=0.0002) Rosenhek, R. Eur Heart J 2004 25:199-205

  16. 65-yr-old, Peak AV Gradient 30mmHg, Progression of AS of 5mmHg/Yr Event Free Death 1995-2000, 1,344,100 CABG, CABG/AVR, AVR after CABG in STS National Database Smith IV WT. J Am Coll Cardiol 2004;44:1241-7

  17. Should CABG undergo Concomitant AVRin Mild or Moderate AS ?- A Decision Analysis Approach to the Surgical Dilemma - 1995-2000, 1,344,100 CABG, CABG/AVR, AVR after CABG in STS National Database CABG/AVR preferred CABG preferred Age at time of CABG Rate of AS progression: 5mmHg/year Smith IV WT. J Am Coll Cardiol 2004;44:1241-7

  18. 10.4. AVR in Patients Undergoing CABG Class I AVR is indicated in patients undergoing CABG who have severe AS who meet the criteria for valve replacement (see Section 3.1.7).(Level of Evidence: C) ACC/AHA 2006 Guidelines for the Managementof Patient With VHD • Class IIa AVR is reasonable in patients undergoing CABG who have moderate AS(mean gradient 30 to 50 mmHg or Doppler velocity 3 to 4 m/sec).(Level of Evidence: B) • Class IIb AVR may be considered in patients undergoing CABG who have mild AS(mean gradient less than 30 mm Hg or Doppler velocity less than 3 m/sec) when there is evidence, such as moderate severe valve calcification, that progression may be rapid. (Level of Evidence: C) Circulation 2006;114;84-231

  19. Is the Use of IMA a Predictor for Early Complications? Bauer EP. EJCTS 1996;10:248-52

  20. Efficacy of IMA in AVR with CABG No LAD LAD-IMA LAD-SVG LAD-IMA vs LAD-SVG p=0.0017 Gall S. ATS 2000;69:524-30

  21. Effect of LIMA-LAD in AVR with CABG Observed Survival Adjusted Survival Mean F/U Period: average 3.7yrs Karthik S. ATS 2005;80:163-9

  22. Impact of Multiple Grafts in AVR with CABG One graft Two graft Multiple graft P=0.91 2000-2004 378 AVR-CABG at Johns Hopkins Mean F/U Period: average 2.2±1.7yrs Kobayashi KJ. ATS 2007;83:969-78

  23. Long-term Survival according to Valve Type in AVR & CABG PERCENT 100 80 60 40 20 BIOPROSTHESIS, n=218 MECHANICAL, n=253 Lytle BW. JTCS 1988;95:402-14

  24. Comparison of Life Expectancy & Event Free Life Expectancy 11.6yr 59-60yr 10.2yr 11.2yr 58-59yr 8.9yr 9.9yr 8.1yr 8.2yr 7.4yr AVRwithoutCABG AVRwithCABG LE: Life Expectancy EFLE: Event-Free Life Expectancy Puvimanasinghe JPA. EJCTS 2003;23:688-95

  25. Lifetime Risk of SVD with Bioprosthesis, Hemorrhage with Mechanical Valve • AVR without CABG: 63yrs • AVR with CABG: 62yrs Puvimanasinghe JPA. EJCTS 2003;23:688-95

  26. Operative Sequences for AVR & CABG Distal anastomosis at first LeBoutillier III M. Valvular and IHD. In: Cohn LH. Cardiac Surgery in the Adult. 2nd ED. New York: McGraw-Hill Co. 2003;1061

  27. CABG with Mitral Valve disease

  28. Operative Mortality for MVR with/without CABG–STS Database- 20 MV Replace MV Replace+CABG 15 10 Percent 5 0 1994 1995 1996 1997 1998 1999 2000 2001 Procedure year Combinded Procedures. In: Surgery of Coronary artery disease, Wheatley DJ. London: Arnold 2003, 326-33

  29. Long-term Survival after MVR & CABG Lytle BW. Circulation 1985;71:1179-90

  30. Survival after MVR with or without CAD Unmatched Cohort Matched Cohort NO CAD P=0.07 P<0.05 CAD and CABG CAD, No CABG 1969-1982, 419 MVR patients No CAD: 216 CAD with CABG: 179 CAD without CABG: 24 No CAD vs CABG P=0.07 CABG vs CAD, No CABG P<0.05 Czer LSC. Circulation 1984;70 (suppl I):I-198-I-207

  31. Survival after MVR& Incidental CAD (Rheumatic) P<0.05 NO CAD CAD and CABG CAD, No CABG Czer LSC. Circulation 1984;70 (suppl I):I-198-I-207

  32. Survival after MVR with/without CAD Hosp. Mortality 1.0 5.6% No CAD(N=934) Mean Age 54yrs 14.2% 0.8 0.6 p<0.0001 Survival CAD(N=340) Mean Age 64yrs 0.4 0.2 0.0 2 4 6 8 0 10 Time (Yrs) Jones EL. ATS 1994;58:378-85

  33. Survival of MVR with CABGbased on Etiology of MVD P=0.02 Lytle BW. Circulation 1985;71:1179-90

  34. Survival according to Etiology P<0.01 Rheumatic Ischemic Other Czer LSC. Circulation 1984;70 (suppl I):I-198-I-207

  35. Survival of Combined MVD & CABGbased on Etiology of MVD Jan 1984- Dec 1997 262 MVR with CABG Survival Rate 1.0 0.8 Hospital Mortality Ischemic: 19.5% Rheumatic 7.9% Degenerative: 2.4% Degenerative MVD 0.6 Ischemic MVD Rheumatic MVD 0.4 P=NS 0.2 0 Years 0 2 4 6 8 10 Seipelt RG. EJCTS 2001;20:270-5

  36. Degenerative MR with CAD vs Ischemic MR Unadjusted Survival Adjusted Survival p<0.0001 p>0.9 Ischemic MR Degenerative MR with CAD One disease Two disease MR±LV dysfunction LV dysfunction→ MR Gillinov AM. ATS 2005;80:811-9

  37. Degenerative MR with CAD vs Ischemic MR Ischemic MR Degenerative MR Homogeneous Survival Curve Inhomogeneous Survival Curve Severity of CADandLV dysfunction impact on Survival Gillinov AM. ATS 2005;80:811-9

  38. Late Outcome of MV Surgery & CABG Dahlberg PS. ATS 2003;76:1539-48

  39. Overall Survival for Repair and Replace for association of CABG Akins CW. ATS 1994;58:668-76

  40. No Survival Benefit in Mitral Repair and CABG Matched Case-Control Study Thourani VH. Circulation 2003;108:298-304

  41. Overall Survival for Repair and Replace for association of CABG With CABG Without CABG 73±7% 74±8% 61±5% Overall survival (%) Repair 34±8% Replacement P=0.0002 P=0.0008 Years • Jan 1980-Dec 1989, 409 Organic MR (except Ischemic MR) • Repair 195, Replacement 214 Enrinquez-Sarano M. Circulation 1995;91:1022-8

  42. Survival for Repair and Replacement for concomitant CABG P<0.01 • 1980- 1995, 1344 Pure MR • Repair 897, Replacement 447 Enriquez-Sarano M. Circulation 2003;108:253-6

  43. Repair vs Replacement for Degenerative MVD with IHD • 1973- 1999, 679 Degenerative MR with CABG • Repair 447, Replacement 232 Gillinov AM. JTCS 2003;125:1350-62

  44. Repair vs Replacement for Degenerative MVD with IHD Survival benefit of Repair Gillinov AM. JTCS 2003;125:1350-62

  45. Operative Sequencesfor MVR & CABG LeBoutillier III M. Valvular and IHD. In: Cohn LH. Cardiac Surgery in the Adult. 2nd ED. New York: McGraw-Hill Co. 2003;1066

  46. Experiences in St. Paul’s Hospital

  47. Experiences in St. Paul’s Hospital

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