1 / 48

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.

brice
Télécharger la présentation

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

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related