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Transcript of DEPARTMENT OF THORACIC & CARDIOVASCULAR SURGERY ST. PAUL’S HOSPITAL THE CATHOLIC UNIVERSITY OF...
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