Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
Year : 2013  |  Volume : 16  |  Issue : 2  |  Page : 92-93
Invited Commentary

Chair- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, United States

Click here for correspondence address and email

Date of Web Publication29-Mar-2013

How to cite this article:
Ramakrishna H. Invited Commentary. Ann Card Anaesth 2013;16:92-3

How to cite this URL:
Ramakrishna H. Invited Commentary. Ann Card Anaesth [serial online] 2013 [cited 2022 Jan 24];16:92-3. Available from:

In this issue of the Annals of Cardiac Anaesthesia, Tempe et al,[1] evaluate the incidence and implications of coronary artery disease (CAD) in Indian patients presenting for valve surgery. With the significant progress in coronary artery stenting worldwide (particularly drug eluting stents) fewer patients are presenting for the surgical management of CAD as reflected by the growing data in the interventional cardiology literature demonstrating the long term durability and safety of percutaneous coronary interventions (PCI). [2],[3] Patients presenting for the surgical management of valvular disease however continue to increase - particularly, aortic valve (in the western world) and the burden of flow limiting CAD in these patients is significant. Given the association of severe stenotic or regurgitant valve lesions in conjunction with CAD, these are high risk patients that need skilled management teams to reduce overall perioperative complication rates.

In patients presenting for valve surgery, routine coronary angiography is performed preoperatively, given the high associated incidence of CAD - particularly in patients with aortic and mitral valve disease. More than 33% of patients with aortic stenosis (AS) who are undergoing aortic valve replacement (AVR) have CAD. [4] Among patients with AS, the prevalence of CAD is 40% to 50% in those with typical angina, an average 25% in those with atypical chest pain, and an average 20% in those without chest pain [4],[5] Given the impact of untreated CAD in these high risk patients with valve disease, preoperative identification of CAD is of great importance in patients with AR or MS and those with AS. Thus, in symptomatic patients and/or those with LV dysfunction, preoperative coronary angiography is recommended in men aged greater than 35 years, premenopausal women aged greater than 35 years with coronary risk factors, and postmenopausal women. [6]

There has been data demonstrating that incomplete revascularization is associated with greater postoperative systolic dysfunction and reduced survival rates after valve surgery compared with patients who receive complete revascularization. [7],[8],[9]

This prospective observational study investigated 140 Indian patients older than 40 years schedule for valve replacement, no exclusion criteria were noted. 21 patients screened were noted to have CAD. Although the primary end point of the study was the incidence of CAD in patients older than 40, the secondary endpoints included outcomes after combined surgery (post operative ICU data, re-exploration for bleeding, hospital length of stay and mortality). As would be expected diabetes and hypertension were more commonly associated in the patients with CAD. In the group 2 which included the combined CABG - valve surgery patients, CABG-AVR was performed in 10 patients, CABG-MVR in 2 patients and CABG-DVR in 1 patient. The majority of the revascularizations were for patients with double-vessel disease. Of note, the combined CABG - valve group was older and had higher Euroscore compared with group 1 (the valve only group). Also, unlike the valve only group where the majority of patients had rheumatic mitral disease needing mitral valve replacement, the combined group had principally aortic valve disease as previously noted. Group 2 patients showed longer bypass and cross clamp times which were not statistically significant. There were no significant differences in ICU and hospital length of stay as well as re-explorations for bleeding between the two groups. From a surgical standpoint it is noteworthy that retrograde cardioplegia was not used in either of the groups. Myocardial protection consisted only of cold anterograde cardioplegia delivered into the aortic root. In terms of surgical mortality, 6 patients died in the combined valve - CABG group, 5 of these had severe AS and the sixth with severe MS, giving this group an overall, high mortality of 28.5%. This is surprisingly high given that the literature reports data substantially lower as the authors mention. The authors speculate that possible reasons for this could be the relatively more severe degrees of LVH and smaller aortic valve areas in the CABG-AVR group that died (1.5-1.75 cm and 0.8-1.2 cm 2 respectively); however, these numbers do not seem higher than average by western standards. The absence of retrograde cardioplegia delivery in these patients - (both cold and warm) is striking, in this writer's opinion. This is considered a gold standard (along with concomitant anterograde delivery) in high risk CABG-AVR and MVR patients in the western world especially in patients with tight coronary lesions, calcified, stenotic aortic valves in association with ventricular hypertrophy and associated chronic diastolic dysfunction/heart failure. The authors do mention subendocardial ischemia as a highly likely causative factor in the group 2 mortality.

In summary this study adds to the large body of literature on the high risk patient presenting for the combined valve-revascularization procedure and re-enforces the fact that a sound plan for myocardial protection must be an integral part of surgical planning. In addition, patients with low ejection fraction, ischemic and non ischemic cardiomyopathy, pulmonary hypertension and renal failure represent higher-risk subsets with the need for skilled perioperative management to reduce overall morbidity and mortality. Given the aging populations worldwide, we can expect to see far greater numbers of patients presenting with combined valve-CAD. The future will see greater percentages of these patients treated with "hybrid" procedures: PCI in the setting of percutaneous aortic valve replacement (TAVR) for patients with CAD and severe AS needing AVR, given the fact that TAVR is now being performed in lower risk patients. [10]

   References Top

1.Tempe DK, Virmani S, Gupta R, Datt V, Joshi C, Dhingra A, et al. Incidence and implications of coronary artery disease in patients undergoing valvular heart surgery: The Indian scenario. Annals of Cardiac Anaesthesia 2013;16:86-91.  Back to cited text no. 1
2.Aversano T, Lemmon CC, Liu L, Atlantic CPORT Investigators. Outcomes of PCI at hospitals with or without on-site cardiac surgery. N Engl J Med 2012;366:1792-802.  Back to cited text no. 2
3.Bangalore S, Kumar S, Fusaro M, Amoroso N, Attubato MJ, Feit F, et al. Short- and long-term outcomes with drug-eluting and bare-metal coronary stents: A mixed-treatment comparison analysis of 117 762 patient-years of follow-up from randomized trials. Circulation 2012;125:2873-91.  Back to cited text no. 3
4.Morrison GW, Thomas RD, Grimmer SF, Silverton PN, Smith DR. Incidence of coronary artery disease in patients with valvular heart disease. Br Heart J 1980;44:630-7.  Back to cited text no. 4
5.Graboys TB, Cohn PF. The prevalence of angina pectoris and abnormal coronary arteriograms in severe aortic valvular disease. Am Heart J 1977;93:683-6.  Back to cited text no. 5
6.Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008;118:e523-661.  Back to cited text no. 6
7.Schaff HV, Bixler TJ, Flaherty JT, Brawley RK, Donahoo JS, Goldman RA, et al. Identification of persistent myocardial ischemia in patients developing left ventricular dysfunction following aortic valve replacement. Surgery 1979;86:70-7.  Back to cited text no. 7
8.Hwang MH, Hammermeister KE, Oprian C, Henderson W, Bousvaros G, Wong M, et al. Preoperative identification of patients likely to have left ventricular dysfunction after aortic valve replacement. Participants in the Veterans Administration Cooperative Study on Valvular Heart Disease. Circulation 1989;80:I65-76.  Back to cited text no. 8
9.Roberts DL, DeWeese JA, Mahoney EB, Yu PN. Long-term survival following aortic valve replacement. Am Heart J 1976;91:311-7.  Back to cited text no. 9
10.Kodali SK, Moses JW. Coronary Artery Disease and Aortic Stenosis in the Transcatheter Aortic Valve Replacement Era: Old Questions, New Paradigms: The Evolving Role of Percutaneous Coronary Intervention in the Treatment of Patients With Aortic Stenosis. Circulation 2012;125; 975-7.  Back to cited text no. 10

Correspondence Address:
Harish Ramakrishna
Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic
United States
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Source of Support: None, Conflict of Interest: None

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