Should coronary artery bypass graft surgery patients with mild or moderate aortic stenosis undergo concomitant aortic valve replacement?
A decision analysis approach to the surgical dilemma
William T. Smith, IV, MD*,
T. Bruce Ferguson, Jr, MD ,
Thomas Ryan, MD, FACC*,
Carolyn K. Landolfo, MD, FACC* and
Eric D. Peterson, MD, MPH, FACC*,*
* Duke University Medical Center, Durham, North Carolina, USA
Louisiana State University, New Orleans, Louisiana, USA
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Figure 1 Schematic representation of Markov decision model structure. AS = aortic stenosis; AVR = aortic valve replacement; CABG = coronary artery bypass graft surgery.
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Figure 2 Using quality-adjusted survival as the outcome measure, at low baseline gradients and in older patients, CABG alone is the preferred strategy for management of a patient with mild, asymptomatic aortic stenosis undergoing coronary bypass surgery. CABG/AVR is favored for patients of all ages with a valve gradient over 50 mm Hg, and for patients under age 70 once their valve gradient reaches about 28 mm Hg. This assumes a constant rate of AS progression of 5 mm Hg/year. Abbreviations as in Figure 1.
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Figure 3 As the rate of progression of aortic stenosis increases from 3 mm Hg/year to 11 mm Hg/year, CABG alone (hatched areas) is favored in a smaller subset of patients. At a rate of 3 mm Hg/year, nearly all patients with mild AS should undergo CABG alone; at a rate of 11 mm Hg/year, only the elderly with very low gradients should be considered for CABG without coincident AVR. Abbreviations as in Figure 1.
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