title: The prognostic impact of concomitant coronary artery bypass grafting during aortic valve surgery: implications for revascularization in the transcatheter era.
abstract: OBJECTIVE
  Clinicians may give greater consideration to medical management versus coronary artery bypass grafting (CABG) for coronary artery disease (CAD) at the time of aortic valve intervention. We evaluated the prognostic impact of revascularization strategy during aortic valve replacement (AVR).
  
  
  METHODS
  We studied 1308 consecutive patients with significant CAD (≥50% stenosis) undergoing AVR with or with out CABG between 2001 and 2010. Late mortality and its determinants were analyzed using multivariable Cox models.
  
  
  RESULTS
  Patients undergoing CABG (n = 1043; 18%) had more frequent angina (50% vs 26%; P < .001), left ventricular dysfunction (22% vs 14%; P = .003), advanced (>70% stenosis) CAD (85% vs 48%; P < .001), and incidence of triple-vessel/left-main CAD (44% vs 8%; P < .001). Whereas operative mortality was comparable between patients undergoing AVR plus CABG versus isolated AVR (2.9% vs 3.0%; P = .90), 5-year (72% vs 64%) and 8-year (50% vs 39%) survival was higher following CABG (P = .007). Adjusting for older age (hazard ratio [HR], 1.28 per 5 years), female sex (HR, 1.23), peripheral vascular disease (HR, 1.71), New York Heart Association functional class III to IV (HR, 1.48), and diabetes (HR, 1.50) concomitant CABG at AVR reduced late mortality risk by more than one-third (HR, 0.62, 95% confidence interval, 0.49-0.79; P < .001). CABG continued to confer a survival advantage in patients with moderate (50%-70%) (HR, 0.62; P = .02) and severe (>70%) CAD (HR, 0.62; P = .002).
  
  
  CONCLUSIONS
  In patients undergoing AVR with coexistent CAD, concomitant CABG reduces risk of late death by more than one-third, without augmenting operative mortality. This survival advantage persists in moderate (50% to 70%) and severe (>70%) CAD. These findings underline the prognostic importance of revascularization in this population and should influence decisions regarding revascularization strategy in patients undergoing transcatheter valve therapy.
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Nassir M
authors.initials: NM
authors.lastname: Thalji
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn. Electronic address: suri.rakesh@mayo.edu.
authors.forename: Rakesh M
authors.initials: RM
authors.lastname: Suri
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Richard C
authors.initials: RC
authors.lastname: Daly
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Kevin L
authors.initials: KL
authors.lastname: Greason
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Dearani
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: John M
authors.initials: JM
authors.lastname: Stulak
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Lyle D
authors.initials: LD
authors.lastname: Joyce
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Harold M
authors.initials: HM
authors.lastname: Burkhart
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Alberto
authors.initials: A
authors.lastname: Pochettino
authors.affiliation: Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minn.
authors.forename: Zhuo
authors.initials: Z
authors.lastname: Li
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Frye
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Hartzell V
authors.initials: HV
authors.lastname: Schaff
mesh_terms: D000368:Aged; D001024:Aortic Valve Stenosis / Q000150:complications* / Q000401:mortality / Q000601:surgery*; D017023:Coronary Angiography; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000150:complications* / Q000401:mortality / Q000601:surgery*; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000379:methods* / Q000401:mortality; D006801:Humans; D008297:Male; D011379:Prognosis; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome