Prevalence and Prediction of Obstructive Coronary Artery Disease in Patients Undergoing Primary Heart Valve Surgery

Prediction of obstructive coronary artery disease in patients undergoing heart valve surgery: A cross-sectional study in a tertiary care hospital

Introduction: Estimating the probability of obstructive coronary artery disease in patients undergoing noncoronary cardiac surgery should be considered compulsory. Our study sought to evaluate the prevalence of obstructive coronary artery disease in patients undergoing valvular heart surgery and to utilize predictive methodology of concomitant obstructive coronary artery disease in these patients. Methods: The retrospective study cohort was derived from a tertiary care hospital registry of patients undergoing coronary angiogram prior to valvular heart operations. Decision tree, logistic regression, and support vector machine models were built to predict the probability of the appearance of obstructive coronary artery disease. A total of 367 patients from 2016 to 2019 were analyzed. Results: The mean age of the study population was 57.3±9.3 years, 45.2% of the patients were male. Of 367 patients, 76 (21%) patients had obstructive coronary artery disease. The decision tree, logistics regression, and support vector machine models had an area under the curve of 72% (95% CI: 62% - 81%), 67% (95% CI: 56% - 77%), and 78% (95% CI: 68% - 87%), respectively. Multivariate analysis indicated that hypertension (OR 1.98; P=0.032), diabetes (OR 2.32; P=0.040), age (OR 1.05; P=0.006), and typical angina (OR 5.46; P<0.001) had significant role in predicting the presence of obstructive coronary artery disease. Conclusion: Our study revealed that approximately one-fifth of patients who underwent valvular heart surgery had concomitant obstructive coronary artery disease. The support vector machine model showed the highest accuracy compared to the other model.

Contemporary prevalence of coronary artery disease in patients referred for heart valve surgery

BACKGROUND

Patients undergoing heart valve surgery are routinely evaluated for the presence of coronary artery disease (CAD). Currently, concomitant valve intervention and surgical revascularization is recommended when there is obstructive CAD. The aim of our study was to evaluate the prevalence of CAD, its treatment strategies, and their prognostic implications in a contemporary population of patients with valvular heart disease (VHD) referred for valve surgery (HVS).

METHODS

In a multicenter registry, consecutive patients with formal indication for HVS referred for a preoperative routine invasive coronary angiogram (ICA) were analyzed. Baseline characteristics, CAD prevalence and revascularization patterns, as well as their impact on short and mid-term all-cause mortality, were assessed.

RESULTS

Overall, 1133 patients were included; most had aortic stenosis (69%) and obstructive CAD was present in 307 (27.1%). HVS was ultimately performed in 82.3%. In patients with CAD, 53.4% were revascularized. After a mean follow-up time of 29.06±18.46 months, all-cause mortality rate was 12.9%. In multivariate analysis, not having HVS (HR 6.845, 95% CI=4.281-10.947, P<0.001), obstructive CAD (HR 2.762, 95% CI=1.764-4.326, P<0.01), COPD (HR 2.043, 95% CI=1.014-4.197, P=0.022), and age (HR 1.030, 95% CI=1.009-1.063, P=0.047), were independent predictors of all-cause mortality. In patients with obstructive CAD who underwent HVS, revascularization was not significantly associated with survival (HR 2.127, 95% CI=0.0-4.494, P=0.048; log rank P=0.042).

CONCLUSIONS

In a contemporary cohort of patients with VHD and surgical indication, overall obstructive CAD prevalence was 27%. CAD presence and severity were associated with higher mortality. However, revascularization was not associated with a survival benefit, except in patients with left anterior descending artery disease.

Implementation of CT Coronary Angiography as an Alternative to Invasive Coronary Angiography in the Diagnostic Work-Up of Non-Coronary Cardiac Surgery, Cardiomyopathy, Heart Failure and Ventricular Arrhythmias

To assess the need for additional invasive coronary angiography (CAG) after initial computed tomography coronary angiography (CTCA) in patients awaiting non-coronary cardiac surgery and in patients with cardiomyopathy, heart failure or ventricular arrhythmias, and to determine differences between patients that were referred to initial CTCA or direct CAG, consecutive patients were included between August 2017 and January 2020 and categorized as those referred to initial CTCA (conform protocol), and to direct CAG (non-conform protocol). Out of a total of 415 patients, 78.8% (327 patients, mean age: 57.9 years, 67.3% male) were referred to initial CTCA, of whom 260 patients (79.5%) had no obstructive lesions (<50% DS). A total of 55 patients (16.8%) underwent additional CAG after initial CTCA, which showed coronary lesions of >50% DS in 21 patients (6.3% of 327). Eighty-eight patients (mean age: 66.0 years, 59.1% male) were directly referred to CAG (non-conform protocol). These patients were older and had more cardiovascular risk factors compared to patients that underwent initial CTCA (conform protocol), and coronary lesions of >50% DS were detected in 16 patients (17.2%). Revascularization procedures were infrequently performed in both groups: initial CTCA (3.0%), direct CAG (3.4%). The use of CTCA as a gatekeeper CAG in the diagnostic work-up of non-coronary cardiac surgery, cardiomyopathy, heart failure and ventricular arrhythmias is feasible, and only 17% of these patients required additional CAG after initial CTCA. Therefore, CTCA should be considered as the initial imaging modality to rule out CAD in these patients.

Coronary artery disease is associated with valvular heart disease, but could it Be a predictive factor?

OBJECTIVE

This study was conducted to evaluate the prevalence of significant coronary artery disease (CAD) in patients with severe valvular heart disease (VHD) and the association between these two cardiac entities. Our research aims to introduce the theory of a possible causal relationship.

METHODS

A retrospective study was conducted on 1308 consecutive patients who underwent surgery for severe VHD in the cardiovascular department of Notre-Dame de Secours University Hospital (NDSUH) between December 2000 and December 2016. According to transthoracic echocardiography, patients were divided into 4 groups: patients with severe aortic stenosis (AS), patients with severe aortic regurgitation (AR), patients with severe mitral stenosis (MS), and patients with severe mitral regurgitation (MR). Preoperative coronary angiographies were reviewed for the presence or the absence of significant CAD (≥50% luminal stenosis). Chi-square test and 2 × 2 tables were used.

RESULTS

Of the 1308 patients with severe VHD, 1002 patients had isolated aortic valve disease, 240 patients had isolated mitral valve disease, and 66 patients had combined aortomitral valve disease. CAD was detected in 27.75% of all patients with severe VHD, in 32% of patients with isolated aortic valve disease, and in 15% of patients with isolated mitral valve disease. Statistical analysis showed a higher prevalence in patients with severe aortic valve stenosis and a significant relationship between CAD and aortic valve disease, mainly severe AS (p < 0.0001).

CONCLUSION

The prevalence of CAD in patients with VHD is 27.75%, and it correlates significantly with aortic valve disease, in particular with severe AS. Future large studies are needed to evaluate the possible causal relationship.