Trends and outcomes of concomitant aortic valve replacement and coronary artery bypass grafting in the UK and a survey of practices

OBJECTIVES
Concomitant revascularization of coronary artery disease at the same time as treatment for aortic valvopathy favourably impacts survival. However, combined surgery maybe associated with increased adverse outcomes compared to aortic valve replacement or coronary artery bypass grafting in isolation.

METHODS
We retrospectively analyzed all patients who underwent aortic valve replacement with bypass grafting between February 1996 and March 2019 using data from the National Adult Cardiac Surgery Audit. We used a generalized mixed-effects model to assess the effect of the number and type of bypass grafts associated with surgical aortic valve replacement on in-hospital mortality, postoperative stroke, and the need for renal dialysis. Furthermore, we conducted an international cross-sectional survey of cardiac surgeons to explore their views about concomitant aortic valve replacement with coronary bypass grafting interventions.

RESULTS
Fifty-one thousand two hundred and seventy-two patients were included in the study. Patients receiving two or more bypass grafts demonstrated more significant pre-operative comorbidity and disease severity. Patients undergoing two and more than two grafts in addition to aortic valve replacement had increased mortality as compared to patients undergoing aortic valve replacement and only one graft (OR 1.17 95% CI [1.05–1.30], p = 0.005 and OR 1.15 95% [1.02–1.30], p = 0.024 respectively). A single arterial conduit was associated with a reduction in mortality (OR 0.75 95% CI [0.68–0.82], p < 0.001), and post-operative dialysis (OR 0.87 95% CI [0.78–0.96], p = 0.006), but this association was lost with more than one arterial conduit.

One hundred and three surgeons responded to our survey, with only a small majority believing that the number of bypass grafts can influence short or long-term post-operative outcomes in these patients, and an almost equal split in responders supporting the use of staged or hybrid interventions for patients with concomitant pathology.

CONCLUSIONS
The number of grafts performed during combined AVR and CABG is associated with increased morbidity and mortality. The use of an arterial graft was also associated with reduced mortality. Future studies are needed to assess the effect of incomplete revascularisation and measure long-term outcomes. Based on our data, current published evidence, and the collective expert opinion we gathered, we endorse future work to investigate the short and long-term efficacy and safety of hybrid intervention for patients with concomitant advanced coronary and aortic valve disease.