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DEPARTMENT OF THORACIC & CARDIOVASCULAR SURGERY ST. PAUL’S HOSPITAL THE CATHOLIC UNIVERSITY OF KOREA CHAN BEOM PARK SURGICAL STRATEGRY FOR CABG WITH ASSOCIATED.

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Presentation on theme: "DEPARTMENT OF THORACIC & CARDIOVASCULAR SURGERY ST. PAUL’S HOSPITAL THE CATHOLIC UNIVERSITY OF KOREA CHAN BEOM PARK SURGICAL STRATEGRY FOR CABG WITH ASSOCIATED."— Presentation transcript:

1 DEPARTMENT OF THORACIC & CARDIOVASCULAR SURGERY ST. PAUL’S HOSPITAL THE CATHOLIC UNIVERSITY OF KOREA CHAN BEOM PARK SURGICAL STRATEGRY FOR CABG WITH ASSOCIATED VALVE SURGERY

2 대한흉부외과학회 제 24 차 춘계학술대회 Combinded Procedures. In: Surgery of Coronary artery disease, Wheatley DJ. London: Arnold 2003, 326-33. STS Database Jan 1992-Dec 2001 CABG75.2% 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%

3 대한흉부외과학회 제 24 차 춘계학술대회 [ http://www.ktcs.or.kr/ ] 대한흉부외과학회 Database 2001-2005 1968 1700 2176 2340 2055 123 147145 185 213

4 대한흉부외과학회 제 24 차 춘계학술대회 CABG with Aortic Valve disease

5 대한흉부외과학회 제 24 차 춘계학술대회 AV Replace AV Replace+CABG Procedure year Percent 19941995199619971998199920002001 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 with or without CABG – STS Database-

6 대한흉부외과학회 제 24 차 춘계학술대회 Lytle BW. JTCS 1988;95:402-14 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

7 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) Survival 051015 20 0.0 0.2 0.4 0.6 0.8 1.0 Survival after AVR with/without CABG

8 대한흉부외과학회 제 24 차 춘계학술대회 Stewart BF. JACC 1997;29:630-4 VariableP valueOdds Ratio95% Confidence Limits Age<0.0012.18*2.15,2.20 Male gender<0.0012.031.7,2.5 Lp(a)<0.0011.23†1.14,1.32 Height(cm)0.0010.84‡0.75,0.93 HBP0.0021.231.1,1.4 Smoking0.0061.351.1,1.7 LDLc(mg/dl)0.0081.12†1.03,1.23 *±75 th vs 25 th percentile. †±10-year increase. ‡±10unit increase. LDLc=low density lipoprotein cholesterol; Lp(a)=lipoprotein(a) Clinical Factors associated with Calcific Aortic Valve disease

9 대한흉부외과학회 제 24 차 춘계학술대회 Pohle K. Circulation 2001;104:1927-32 AV Calcification associated with Coronary Atherosclerosis

10 대한흉부외과학회 제 24 차 춘계학술대회 Atherosclerotic Changes in Aortic Valves of Hypercholesterolemic Rabbits Aortic Valve-Cholesterol diet Aorta-Cholesterol diet Aorta-Normal diet

11 대한흉부외과학회 제 24 차 춘계학술대회 Fiore AC. ATS 1996;61:1693-8 CABG then AVR CABG with AVR Mild AS >1.0cm 2 26±10mmHg 1.05±0.2cm 2 61.3±26mmHg 0.69±0.12cm 2 8.9yr CABG then AVRCABG/AVR 53.2±24mmHg 0.73±0.21cm 2 Management of Asx Mild AS during CABG p = NS PERCENTPERCENT YEARS 100 80 60 40 20 0 021345678910

12 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 AVR (CABG) vs AV Reop (AVR/CABG) in Mild to Moderate AV Disease P=0.0024 CABG AVR/CABG

13 대한흉부외과학회 제 24 차 춘계학술대회 Mild AS : Mean PG 1.5cm 2 Moderate AS : Mean PG≥30mmHg and ≤40mmHg, and/or Valve area >1.0 and ≤ 1.5cm 2 Pereira JJ. Am J Med 2005;118:735-42 Survival after Mild/Moderate AVR with CABG AVR-CABG CABG

14 대한흉부외과학회 제 24 차 춘계학술대회 Tom JW. ATS 1998;65:1215-9 1375926480 yrs Progression of Mild AS in CABG Patients Variable Event-Free Survivors Progression to Severe AS P value Age(yr)61.1±9.560.0±9.6NS AS gradient (mmHg) 9.6±7.120.7±9.90.0005 Calcium score0.8±0.71.3±0.70.06 Mobility score0.9±0.81.0±0.9NS

15 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 Outcome - Calcification, AV velocity, CAD -

16 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 Death Event Free 65-yr-old, Peak AV Gradient 30mmHg, Progression of AS of 5mmHg/Yr

17 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 AVR in Mild or Moderate AS ? - A Decision Analysis Approach to the Surgical Dilemma - Age at time of CABG

18 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

19 대한흉부외과학회 제 24 차 춘계학술대회 Bauer EP. EJCTS 1996;10:248-52 VariableIMA(n=68)SVG(n=120)P value Non-survivors4(6%)6(5%)NS Mechanical ventilation(hours)30±4.821±3.5NS Catecholamine support34(50%)67(56%)NS CK-MB(highest value)43±3.042±4.2NS Transfusion30(44%)62(52%)NS ICU stay(days)4.4±0.74.0±0.3NS Rethoracotomy1(1.5%)2(1.6%)NS Sternal wound infection01(0.8%)NS Ustable sternum1(1%)0NS Is the Use of IMA a Predictor for Early Complications?

20 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 CABG

21 대한흉부외과학회 제 24 차 춘계학술대회 Observed SurvivalAdjusted Survival Karthik S. ATS 2005;80:163-9 Mean F/U Period: average 3.7yrs Effect of LIMA-LAD in AVR with CABG

22 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 CABG P=0.91 Mean F/U Period: average 2.2±1.7yrs

23 대한흉부외과학회 제 24 차 춘계학술대회 Lytle BW. JTCS 1988;95:402-14 PERCENT 100 60 40 20 80 BIOPROSTHESIS, n=218 MECHANICAL, n=253 Long-term Survival according to Valve Type in AVR & CABG

24 대한흉부외과학회 제 24 차 춘계학술대회 Puvimanasinghe JPA. EJCTS 2003;23:688-95 AVR without CABGAVR with CABG LE: Life Expectancy EFLE: Event-Free Life Expectancy 11.6yr 11.2yr 8.9yr 8.2yr 9.9yr 10.2yr 7.4yr 8.1yr 59-60yr 58-59yr Comparison of Life Expectancy & Event Free Life Expectancy

25 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 Bioprosthesis, Hemorrhage with Mechanical Valve

26 대한흉부외과학회 제 24 차 춘계학술대회 LeBoutillier III M. Valvular and IHD. In: Cohn LH. Cardiac Surgery in the Adult. 2 nd ED. New York: McGraw-Hill Co. 2003;1061 Operative Sequences for AVR & CABG Distal anastomosis at first

27 대한흉부외과학회 제 24 차 춘계학술대회 CABG with Mitral Valve disease

28 대한흉부외과학회 제 24 차 춘계학술대회 Combinded Procedures. In: Surgery of Coronary artery disease, Wheatley DJ. London: Arnold 2003, 326-33 Percent 20 15 10 5 Procedure year 19941995199619971998199920002001 MV Replace MV Replace+CABG 0 Operative Mortality for MVR with/without CABG – STS Database-

29 대한흉부외과학회 제 24 차 춘계학술대회 Lytle BW. Circulation 1985;71:1179-90 Long-term Survival after MVR & CABG

30 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 CohortMatched Cohort NO CAD CAD and CABG CAD, No CABG P=0.07 P<0.05 Survival after MVR with or without CAD No CAD vs CABG P=0.07 CABG vs CAD, No CABG P<0.05

31 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 MVR & Incidental CAD (Rheumatic)

32 대한흉부외과학회 제 24 차 춘계학술대회 Jones EL. ATS 1994;58:378-85 Hosp. Mortality 5.6% 14.2% No CAD(N=934) Mean Age 54yrs CAD(N=340) Mean Age 64yrs p<0.0001 Time (Yrs) Survival 0.0 0.2 0.4 0.6 0.8 1.0 010 2468 Survival after MVR with/without CAD

33 대한흉부외과학회 제 24 차 춘계학술대회 Lytle BW. Circulation 1985;71:1179-90 P=0.02 Survival of MVR with CABG based on Etiology of MVD

34 대한흉부외과학회 제 24 차 춘계학술대회 Rheumatic P<0.01 Ischemic Other Survival according to Etiology Czer LSC. Circulation 1984;70 (suppl I):I-198-I-207

35 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 1997 262 MVR with CABG Survival Rate Degenerative MVD Ischemic MVD Rheumatic MVD Survival of Combined MVD & CABG based on Etiology of MVD 1.0 0.8 0.6 0.4 0.2 0 0246810 Years

36 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<0.0001p>0.9 One diseaseTwo disease Degenerative MR with CAD vs Ischemic MR

37 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

38 대한흉부외과학회 제 24 차 춘계학술대회 Univariate p value Multivariate p value Age > 72yrs0.0001< 0.0001 EF < 35%< 0.00010.0039 Replacement0.0370.019 3-vessel CAD0.00010.0086 Dismissal MR > 20.0190.042 NYHA III/IV0.00020.072 Ischemic0.00360.21 Dahlberg PS. ATS 2003;76:1539-48 Late Outcome of MV Surgery & CABG

39 대한흉부외과학회 제 24 차 춘계학술대회 Overall Survival for Repair and Replace for association of CABG Akins CW. ATS 1994;58:668-76

40 대한흉부외과학회 제 24 차 춘계학술대회 Thourani VH. Circulation 2003;108:298-304 No Survival Benefit in Mitral Repair and CABG Matched Case-Control Study

41 대한흉부외과학회 제 24 차 춘계학술대회 Enrinquez-Sarano M. Circulation 1995;91:1022-8 Overall Survival for Repair and Replace for association of CABG With CABGWithout CABG Repair Replacement P=0.0008 P=0.0002 Years Overall survival (%) 74±8% 34±8% 73±7% 61±5% Jan 1980-Dec 1989, 409 Organic MR (except Ischemic MR) Repair 195, Replacement 214

42 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

43 대한흉부외과학회 제 24 차 춘계학술대회 Gillinov AM. JTCS 2003;125:1350-62 Repair vs Replacement for Degenerative MVD with IHD 1973- 1999, 679 Degenerative MR with CABG Repair 447, Replacement 232

44 대한흉부외과학회 제 24 차 춘계학술대회 Gillinov AM. JTCS 2003;125:1350-62 Survival benefit of Repair Repair vs Replacement for Degenerative MVD with IHD

45 대한흉부외과학회 제 24 차 춘계학술대회 Operative Sequences for MVR & CABG LeBoutillier III M. Valvular and IHD. In: Cohn LH. Cardiac Surgery in the Adult. 2 nd ED. New York: McGraw-Hill Co. 2003;1066

46 대한흉부외과학회 제 24 차 춘계학술대회 Experiences in St. Paul ’ s Hospital AV SurgeryMV Surgery Incidence9/369 (2.4%)12/369 (3.3%) Sex(M:F)5:46:6 Age67.2±6.963.6±7.9 Etiology Degenerative71 Rheumatic13 Congenital1 Ischemic (Functional)7 Ischemic (PM rupture)1 Number of bypass graft1.4±0.72.2±0.8 Graft LIMA8(88.9%)9(75%) SVG5

47 대한흉부외과학회 제 24 차 춘계학술대회 Experiences in St. Paul ’ s Hospital AV SurgeryMV Surgery CPB time (min)229.0±65.9283.1±93.9 ACC time (min)182.6±50.0198.9±45.7 Complications Mediastinitis1 Sudden cardiac arrest1 Pneumonia1 ARF3 Hepatic failure1 Bleeding2 Low cardiac output3 Operative mortality1/9 (11.1%)2/12 (16.7%)

48 대한흉부외과학회 제 24 차 춘계학술대회

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