Management of Mild Aortic Stenosis During Coronary Artery Bypass Graft Surgery

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Abstract
A small proportion of patients with significant coronary artery disease referred for coronary artery bypass graft (CABG) surgery have coexistent congenital or valvular disease that, if isolated, would be inadequately severe to justify surgery. While there is general agreement that CABG should be performed for obstruction of major epicardial arteries even without ischemic symptoms in patients having aortic valve replacement (AVR) for aortic stenosis (AS), there has been little or no consideration of whether “mild-to-moderate” AS should be treated by valve repair or AVR at the time of CABG. Between 1975 and 1992, we performed AVR for symptoms or signs of severe AS without significant ischemia on 44 patients with previous CABG. None of thesepatients were considered to have serious AS at the time of CABG surgery 8 to 164 months (68 months) previously. At aortic surgery, ages ranged from 52 to 83 years (73); 38% were female. In 20 patients with available data, transvalvular gradients ranged from 0 to 23 (12) mmHg at CABG and 29 to 95 (62) mmHg at AVR. Aortic valve areas at CABG ranged from 0.9 to 2.2 (1.5) cm2 and at AVR ranged from 0.3 to 1.7 (0.7) cm2. Appearance of symptoms and signs of severe AS occurred in 16% by 3 years; 45% by 4 years; and 75% by 5 years after CABG surgery. These data observations suggest that mild, asymptomatic valve deformity may progress to symptomatic, hemodynamically severe AS within a short time after CABG surgery, well before recurrent symptoms of coronary obstructive disease. Serious consideration of AVR should be entertained for patients with any degree of aortic valve obstruction who must undergo CABG surgery. (J Card Surg 1994;9[Suppl]:145–147)