DEPARTMENT OF THORACIC & CARDIOVASCULAR SURGERY ST. PAUL’S HOSPITAL THE CATHOLIC UNIVERSITY OF KOREA CHAN BEOM PARK SURGICAL STRATEGRY FOR CABG SURGICAL STRATEGRY FOR CABG WITH ASSOCIATED VALVE WITH ASSOCIATED VALVE SURGERY SURGERY
DEPARTMENT OF THORACIC &
CARDIOVASCULAR SURGERY
ST. PAUL’S HOSPITAL
THE CATHOLIC UNIVERSITY OF KOREA
CHAN BEOM PARK
SURGICAL STRATEGRY FOR SURGICAL STRATEGRY FOR
CABG WITH ASSOCIATED CABG WITH ASSOCIATED
VALVE SURGERYVALVE SURGERY
대한흉부외과학회 제 24 차 춘계학술대회
Combinded Procedures. In: Surgery of Coronary artery disease, Wheatley DJ. London: Arnold 2003, 326-33.
STS Database STS Database Jan 1992-Dec Jan 1992-Dec 20012001
CABGCABG75.2%75.2%
AVR
AVR+CABG
MVR
MVR+CABG
AVR+MVR
MV Repair
MV Repair+CABG
Other
4.18%
4.26%
2.01%
1.37%0.86%0.92%
10.7%
대한흉부외과학회 제 24 차 춘계학술대회
[ http://www.ktcs.or.kr/ ]
대한흉부외과학회 대한흉부외과학회 Database Database 2001-2001-20052005
2527 25412409 2420 2347
0
500
1000
1500
2000
2500
3000
2001 2002 2003 2004 2005
ValveCABGCABG+Valve
1968
1700
21762340
2055
123 147 145 185 213
대한흉부외과학회 제 24 차 춘계학술대회
CABG with Aortic Valve diseaseCABG with Aortic Valve disease
대한흉부외과학회 제 24 차 춘계학술대회
AV Replace
AV Replace+CABG
Procedure year
Pe
rce
nt
1994 1995 1996 1997 1998 1999 2000 2001
Combinded Procedures. In: Surgery of Coronary artery disease, Wheatley DJ. London: Arnold 2003, 326-33.
0
10
8
6
4
2
Operative Mortality for AVR Operative Mortality for AVR with with or or
withoutwithout CABG CABG –STS Database-–STS Database-
대한흉부외과학회 제 24 차 춘계학술대회
Lytle BW. JTCS 1988;95:402-14
Long-term Survival after AVR with Long-term Survival after AVR with CABGCABG
Major cardiac event: reoperation, permanent neurologic event, MI, bleeding, endocarditis, hospitalization for CHF, NYHA III/IV Sx, death
대한흉부외과학회 제 24 차 춘계학술대회
Jones EL. ATS 1994;58:378-85
No CAD(N=1396)Mean Age 56yrs
CAD(N=883)Mean Age 67yrs
Hosp. Mortality
3.4%
7.9%
39%
60%
p<0.0001
Time (Yrs)
Su
rviv
al
0 5 10 15 20
0.0
0.2
0.4
0.6
0.8
1.0
Survival after AVR with/without Survival after AVR with/without CABGCABG
대한흉부외과학회 제 24 차 춘계학술대회
Stewart BF. JACC 1997;29:630-4
VariableP
valueOdds Ratio
95% Confidence Limits
Age <0.001 2.18* 2.15,2.20
Male gender
<0.001 2.03 1.7,2.5
Lp(a) <0.001 1.23† 1.14,1.32
Height(cm)
0.001 0.84‡ 0.75,0.93
HBP 0.002 1.23 1.1,1.4
Smoking 0.006 1.35 1.1,1.7
LDLc(mg/dl)
0.008 1.12† 1.03,1.23*±75th vs 25th percentile. †±10-year increase. ‡±10unit increase. LDLc=low density lipoprotein cholesterol; Lp(a)=lipoprotein(a)
Clinical Factors associated with Clinical Factors associated with Calcific Calcific
Aortic Valve diseaseAortic Valve disease
대한흉부외과학회 제 24 차 춘계학술대회
Pohle K. Circulation 2001;104:1927-32
AV Calcification associated with AV Calcification associated with Coronary AtherosclerosisCoronary Atherosclerosis
대한흉부외과학회 제 24 차 춘계학술대회
Atherosclerotic Changes in Aortic Atherosclerotic Changes in Aortic Valves of Valves of Hypercholesterolemic RabbitsHypercholesterolemic Rabbits
Aortic Valve-Cholesterol diet
Aortic Valve-Cholesterol diet
Aorta-Cholesterol diet
Aorta-Normal diet
대한흉부외과학회 제 24 차 춘계학술대회
Fiore AC. ATS 1996;61:1693-8
CABG then AVR
CABG with AVR
Mild AS >1.0cm2
26±10mmHg1.05±0.2cm2
61.3±26mmHg0.69±0.12cm2
8.9yr
CABG then AVR CABG/AVR
53.2±24mmHg0.73±0.21cm2
Management of Asx Mild AS during Management of Asx Mild AS during
CABGCABG
p = NS
PERCENT
YEARS
100
80
60
40
20
0
0 21 3 4 5 6 7 8 9 10
대한흉부외과학회 제 24 차 춘계학술대회
Hochrein J. Am Heart J 1999;138:791-7
24.3%
3%
Mean AS gradient CABG: 25.9±11.2 (14-66) mmHg AVR/CABG: 52.5±18.9 (14-126) mmHg
Freedom from AVRFreedom from AVR (CABG)(CABG) vs AV Reopvs AV Reop (AVR/CABG)(AVR/CABG)
in Mild to Moderate AV Diseasein Mild to Moderate AV Disease
P=0.0024
CABG
AVR/CABG
대한흉부외과학회 제 24 차 춘계학술대회
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
Survival after Mild/Moderate AVR Survival after Mild/Moderate AVR with CABGwith CABG
AVR-CABG
AVR-CABG
CABG
CABG
대한흉부외과학회 제 24 차 춘계학술대회
Tom JW. ATS 1998;65:1215-9
1 3 75 92 64 80 yrs
Progression of Mild AS in CABG Progression of Mild AS in CABG PatientsPatients
VariableEvent-FreeSurvivors
Progressionto Severe AS
P value
Age(yr) 61.1±9.5 60.0±9.6 NS
AS gradient (mmHg)
9.6±7.1 20.7±9.9 0.0005
Calcium score
0.8±0.7 1.3±0.7 0.06
Mobility score 0.9±0.8 1.0±0.9 NS
대한흉부외과학회 제 24 차 춘계학술대회
Rosenhek, R. Eur Heart J 2004 25:199-205
No CAD (1,3,5yr) : 98±1%, 86±3%, 74±4%
CAD (1,3,5yr) : 94±3%, 63±7%, 40±8% (p=0.0002)
Predictors of OutcomePredictors of Outcome- Calcification, AV velocity, CAD -- Calcification, AV velocity, CAD -
대한흉부외과학회 제 24 차 춘계학술대회
Smith IV WT. J Am Coll Cardiol 2004;44:1241-7
1995-2000, 1,344,100 CABG, CABG/AVR, AVR after CABG
in STS National Database
0
10
20
30
40
50
60
70
Immediate 1yr 5yr 10yr 15yr
CABG CABG/AVR
0
20
40
60
80
100
Immediate 1yr 5yr 10yr 15yr
CABG CABG/AVR
Death Event Free
65-yr-old, Peak AV Gradient 65-yr-old, Peak AV Gradient 30mmHg, Progression of AS of 30mmHg, Progression of AS of
5mmHg/Yr5mmHg/Yr
대한흉부외과학회 제 24 차 춘계학술대회
Smith IV WT. J Am Coll Cardiol 2004;44:1241-7
CABG/AVR preferred
preferredCABG
1995-2000, 1,344,100 CABG, CABG/AVR, AVR after CABG
in STS National Database
Rate of AS progression: 5mmHg/year
Should CABG undergo Concomitant Should CABG undergo Concomitant
AVRAVRin Mild or Moderate AS ?in Mild or Moderate AS ?
- A Decision Analysis Approach to the Surgical Dilemma -- A Decision Analysis Approach to the Surgical Dilemma -
Age at time of CABG
대한흉부외과학회 제 24 차 춘계학술대회
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)
Circulation 2006;114;84-231
• 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)
ACC/AHA 2006 Guidelines for the Management
of Patient With VHD
대한흉부외과학회 제 24 차 춘계학술대회
Bauer EP. EJCTS 1996;10:248-52
Variable IMA(n=68)
SVG(n=120)
P value
Non-survivors 4(6%) 6(5%) NS
Mechanical ventilation(hours)
30±4.8 21±3.5 NS
Catecholamine support 34(50%) 67(56%) NS
CK-MB(highest value) 43±3.0 42±4.2 NS
Transfusion 30(44%) 62(52%) NS
ICU stay(days) 4.4±0.7 4.0±0.3 NS
Rethoracotomy 1(1.5%) 2(1.6%) NS
Sternal wound infection 0 1(0.8%) NS
Ustable sternum 1(1%) 0 NS
Is the Use of IMA a Predictor for Early Is the Use of IMA a Predictor for Early
Complications?Complications?
대한흉부외과학회 제 24 차 춘계학술대회
Gall S. ATS 2000;69:524-30
LAD-IMA vs LAD-SVG
p=0.0017
No LAD
LAD-SVG
LAD-IMA
Efficacy of IMA in AVR with Efficacy of IMA in AVR with
CABGCABG
대한흉부외과학회 제 24 차 춘계학술대회
Observed Survival Adjusted Survival
Karthik S. ATS 2005;80:163-9
Mean F/U Period: average 3.7yrs
Effect of LIMA-LAD in AVR with Effect of LIMA-LAD in AVR with
CABGCABG
대한흉부외과학회 제 24 차 춘계학술대회
Kobayashi KJ. ATS 2007;83:969-78
One graft
Two graft
Multiple graft
2000-2004
378 AVR-CABG at Johns Hopkins
Impact of Multiple Grafts in AVR with Impact of Multiple Grafts in AVR with
CABGCABG
P=0.91
Mean F/U Period: average 2.2±1.7yrs
대한흉부외과학회 제 24 차 춘계학술대회
Lytle BW. JTCS 1988;95:402-14
PERCENT100
60
40
20
80
BIOPROSTHESIS, n=218
MECHANICAL, n=253
Long-term Survival according to Valve Long-term Survival according to Valve Type in AVR & CABGType in AVR & CABG
대한흉부외과학회 제 24 차 춘계학술대회
Puvimanasinghe JPA. EJCTS 2003;23:688-95
AVR without CABG AVR with CABG
LE: Life Expectancy
EFLE: Event-Free Life Expectancy
11.6yr
11.2yr8.9yr
8.2yr
9.9yr
10.2yr
7.4yr
8.1yr
59-60yr 58-
59yr
Comparison of Life Expectancy & Comparison of Life Expectancy &
Event Free Life ExpectancyEvent Free Life Expectancy
대한흉부외과학회 제 24 차 춘계학술대회
Puvimanasinghe JPA. EJCTS 2003;23:688-95
• AVR without CABG: 63yrs
• AVR with CABG: 62yrs
Lifetime Risk of SVD with Lifetime Risk of SVD with
Bioprosthesis, Bioprosthesis,
Hemorrhage with Mechanical ValveHemorrhage with Mechanical Valve
대한흉부외과학회 제 24 차 춘계학술대회
LeBoutillier III M. Valvular and IHD. In: Cohn LH. Cardiac Surgery in the Adult. 2nd ED. New York: McGraw-Hill Co. 2003;1061
Operative Sequences for AVR & Operative Sequences for AVR &
CABGCABG
Distal anastomosis at first
대한흉부외과학회 제 24 차 춘계학술대회
CABG with Mitral Valve diseaseCABG with Mitral Valve diseaseCABG with Mitral Valve diseaseCABG with Mitral Valve disease
대한흉부외과학회 제 24 차 춘계학술대회
Combinded Procedures. In: Surgery of Coronary artery disease, Wheatley DJ. London: Arnold 2003, 326-33
Pe
rce
nt
20
15
10
5
Procedure year
1994 1995 1996 1997 1998 1999 2000 2001
MV Replace
MV Replace+CABG
0
Operative Mortality for MVR Operative Mortality for MVR with/without CABGwith/without CABG –STS Database-–STS Database-
Operative Mortality for MVR Operative Mortality for MVR with/without CABGwith/without CABG –STS Database-–STS Database-
대한흉부외과학회 제 24 차 춘계학술대회
Lytle BW. Circulation 1985;71:1179-90
Long-term Survival after MVR & Long-term Survival after MVR &
CABGCABG
대한흉부외과학회 제 24 차 춘계학술대회
Czer LSC. Circulation 1984;70 (suppl I):I-198-I-207
1969-1982, 419 MVR patients No CAD: 216
CAD with CABG: 179
CAD without CABG: 24
Unmatched Cohort Matched Cohort
NO CAD
CAD and CABG
CAD, No CABG
P=0.07
P<0.05
Survival after MVR with or without Survival after MVR with or without
CADCAD
No CAD vs CABG P=0.07
CABG vs CAD, No CABG P<0.05
대한흉부외과학회 제 24 차 춘계학술대회
Czer LSC. Circulation 1984;70 (suppl I):I-198-I-207
NO CAD
CAD and CABG
CAD, No CABG
P<0.05
Survival after MVRSurvival after MVR & Incidental CAD & Incidental CAD (Rheumatic)(Rheumatic)
대한흉부외과학회 제 24 차 춘계학술대회
Jones EL. ATS 1994;58:378-85
Hosp. Mortality5.6%
14.2% No CAD(N=934)Mean Age 54yrs
CAD(N=340)Mean Age 64yrs
p<0.0001
Time (Yrs)
Su
rviv
al
0.0
0.2
0.4
0.6
0.8
1.0
0 102 4 6 8
Survival after MVR with/without Survival after MVR with/without
CADCAD
대한흉부외과학회 제 24 차 춘계학술대회
Lytle BW. Circulation 1985;71:1179-90
P=0.02
Survival of MVR with CABGSurvival of MVR with CABG based on Etiology of MVDbased on Etiology of MVD
대한흉부외과학회 제 24 차 춘계학술대회
Rheumatic
P<0.01
Ischemic
Other
Survival according to Survival according to
EtiologyEtiology
Czer LSC. Circulation 1984;70 (suppl I):I-198-I-207
대한흉부외과학회 제 24 차 춘계학술대회
Seipelt RG. EJCTS 2001;20:270-5
Hospital Mortality Ischemic: 19.5% Rheumatic 7.9% Degenerative: 2.4%
P=NS
Jan 1984- Dec 1997262 MVR with CABG
Survival Rate
Degenerative MVDIschemic MVD
Rheumatic MVD
Survival of Combined MVD & Survival of Combined MVD &
CABGCABG based on Etiology of MVDbased on Etiology of MVD
1.0
0.8
0.6
0.4
0.2
0
0 2 4 6 8 10Years
대한흉부외과학회 제 24 차 춘계학술대회
Gillinov AM. ATS 2005;80:811-9
Unadjusted Survival Adjusted Survival
Ischemic MR Degenerative MR with CAD
LV dysfunction → MR MR ± LV dysfunction
p<0.0001 p>0.9
One disease Two disease
Degenerative MR with CAD vs Ischemic MR
대한흉부외과학회 제 24 차 춘계학술대회
Gillinov AM. ATS 2005;80:811-9
Ischemic MR
Homogeneous Survival Curve
Degenerative MR
Inhomogeneous Survival Curve
Severity of CAD and LV dysfunction
impact on Survival
Degenerative MR with CAD vs Ischemic MR
대한흉부외과학회 제 24 차 춘계학술대회
Univariate
p value
Multivariate
p value
Age > 72yrs 0.0001 < 0.0001
EF < 35% < 0.0001 0.0039
Replacement 0.037 0.019
3-vessel CAD 0.0001 0.0086
Dismissal MR > 2 0.019 0.042
NYHA III/IV 0.0002 0.072
Ischemic 0.0036 0.21
Dahlberg PS. ATS 2003;76:1539-48
Late Outcome of MV Surgery & Late Outcome of MV Surgery &
CABGCABG
대한흉부외과학회 제 24 차 춘계학술대회
Overall Survival for Repair and Replace
for association of CABG
Akins CW. ATS 1994;58:668-76
대한흉부외과학회 제 24 차 춘계학술대회
Thourani VH. Circulation 2003;108:298-304
No Survival Benefit in Mitral Repair and CABG
Matched Case-Control Study
대한흉부외과학회 제 24 차 춘계학술대회
Enrinquez-Sarano M. Circulation 1995;91:1022-8
Overall Survival for Repair and Replace
for association of CABG
With CABG Without CABG
RepairReplacement
P=0.0008P=0.0002
Years
Ove
rall
su
rviv
al (
%)
74±8%
34±8%
73±7%
61±5%
• Jan 1980-Dec 1989, 409 Organic MR (except Ischemic MR)• Repair 195, Replacement 214
대한흉부외과학회 제 24 차 춘계학술대회
Enriquez-Sarano M. Circulation 2003;108:253-6
Survival for Repair and Replacement
for concomitant CABG
P<0.01
•1980- 1995, 1344 Pure MR • Repair 897, Replacement 447
대한흉부외과학회 제 24 차 춘계학술대회
Gillinov AM. JTCS 2003;125:1350-62
Repair vs Replacement for Repair vs Replacement for
Degenerative Degenerative
MVD with IHDMVD with IHD
• 1973- 1999, 679 Degenerative MR with CABG• Repair 447, Replacement 232
대한흉부외과학회 제 24 차 춘계학술대회
Gillinov AM. JTCS 2003;125:1350-62
Survival benefit of
Repair
Repair vs Replacement for Degenerative MVD with IHD
대한흉부외과학회 제 24 차 춘계학술대회
Operative Operative
SequencesSequencesfor MVR & CABGfor 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
대한흉부외과학회 제 24 차 춘계학술대회
Experiences in St. Paul’s Experiences in St. Paul’s
HospitalHospital
AV Surgery MV SurgeryIncidence 9/369 (2.4%) 12/369 (3.3%)
Sex(M:F) 5:4 6:6
Age 67.2±6.9 63.6±7.9
Etiology
Degenerative 7 1
Rheumatic 1 3
Congenital 1
Ischemic (Functional) 7
Ischemic (PM rupture) 1
Number of bypass graft 1.4±0.7 2.2±0.8
Graft
LIMA 8(88.9%) 9(75%)
SVG 5
대한흉부외과학회 제 24 차 춘계학술대회
Experiences in St. Paul’s Experiences in St. Paul’s
HospitalHospital
AV Surgery MV SurgeryCPB time (min) 229.0±65.9 283.1±93.9
ACC time (min) 182.6±50.0 198.9±45.7
Complications
Mediastinitis 1
Sudden cardiac arrest 1
Pneumonia 1
ARF 3
Hepatic failure 1
Bleeding 2
Low cardiac output 3
Operative mortality 1/9 (11.1%) 2/12 (16.7%)
대한흉부외과학회 제 24 차 춘계학술대회