Background: In patients with severe aortic stenosis (AS) and coronary artery disease (CAD), aortic valve replacement (AVR) is usually performed in conjunction with coronary artery bypass grafting (CABG). Generally, patients with mild and sometimes moderate AS do not require valve replacement during CABG surgery. In many cases, these patients can be managed conservatively; however, some may eventually require AVR as the disease progresses. The risk of early AVR in these patients remains uncertain, making long-term management challenging. This study aims to (1) assess the risk of AVR following CABG and (2) identify factors associated with rapid progression of AS.
METHODS AND RESULTS: This study included 477 patients who underwent late AVR after a previous CABG between 1994 and 2023 at IUCPQ-UL. Patients were classified into three subgroups based on the interval between procedures: < 5 years, 5–10 years, and >10 years. Rapid AS progression was defined as an increase in the aortic valve mean gradient (MG) of ≥5 mmHg/year. Factors associated with early AVR (within 5 years after CABG) and rapid AS progression were identified using Cox regression analysis, and its impact on long-term survival. During a mean follow-up of 11 ± 5.7 years, 63 patients (13%) underwent early AVR. At the CABG surgery, 341 patients had no AS, 117 had mild AS and 18 had moderate AS. In multivariate Cox analysis, factors independently associated with early AVR included age ≥75 years (HR [95% CI]: 2.77 [1.53–4.99]; p< 0.001), an initial MG ≥20 mmHg (HR [95% CI]: 2.36 [1.00–4.46]; p=0.042), diabetes (HR [95% CI]: 1.70 [1.03–2.80]; p=0.036), BMI ≥ 30 kg/m² (HR [95% CI]: 1.69 [1.02–2.58]; p=0.027), and renal insufficiency (HR [95% CI]: 3.81 [1.96–7.42]; p< 0.001). Advanced age ≥75 years (HR [95% CI]: 1.81 [1.02–1.09]; p< 0.001), BMI ≥30 kg/m²(HR [95% CI]: 1.85 [1.12–3.03]; p=0.025), atrial fibrillation (HR [95% CI]: 2.52 [1.08–5.88]; p=0.031), peripheral artery disease (HR [95% CI]: 2.45 [1.19–2.65]; p=0.006) and MG in CABG (HR [95% CI]:1.04 [1.00-1.09]; p=0.048) were independently associated with rapid AS progression. Early AVR showed a trend toward an increased risk of late all-cause mortality (HR [95% CI]: 1.44 [0.98–2.05]; p=0.057).
Conclusion: In patients undergoing CABG, several factors, including advanced age, obesity, an initial MG ≥20 mmHg, diabetes, and renal insufficiency, were independently associated with early AVR. Additionally, atrial fibrillation and peripheral artery disease were factors showing the strongest association with rapid AS progression.
