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(AAN)
[1–8] [PREPRINTER stage]
Original Article
Coronary ostial compromise in aortic valve replacement: An avoidable complication
Asian Cardiovascular & Thoracic Annals 0(0) 1–8 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315573105 aan.sagepub.com
Shakil Farid, Aravinda Page, Neil Howell, Martin Goddard, Yasir Abu-Omar, David P Jenkins and Samer AM Nashef
Abstract Background: We sought to determine the incidence of hospital death due to surgical compromise of the coronary ostia in aortic valve replacement. The mechanism of coronary ostium blockage was also investigated. Methods: A retrospective review was conducted of prospectively collected clinical data and autopsy findings in 322 patients who died in hospital after aortic valve replacement with or without concomitant procedures in a single institution from January 1998 to March 2013. Results: Over the 15-year period, more than 17 surgeons performed 7507 aortic valve replacements with or without other procedures. The mean age of the patients was 70.8 11.78 years and 63% were male. Bioprosthetic valves were used in 75%, mechanical valves in 24.7%, and homografts in only 0.3%. Early mortality for all patients (combined, emergency, and redo procedures) was 4.29% (mean logistic EuroSCORE 10.7). There were 322 deaths after procedures involving the aortic valve. Autopsy examinations were carried out in all patients and showed that 3.4% (n ¼ 11) of deaths were at least partly attributed to encroachment on one or both coronary ostia. Causes of ostial compromise included the valve sutures, the valve sewing ring, and the aortotomy suture line. Conclusions: Coronary ostial compromise in aortic valve replacement is a very rare but real problem occurring in at least 0.15% of aortic valve replacements and contributing to or directly causing one in every 29 aortic valve replacement deaths. Surgeons should have a high level of awareness of the risk of this rare but fatal and avoidable complication.
Keywords Aortic valve, coronary stenosis, heart valve diseases, heart valve prosthesis implantation, postoperative complications
investigate the prevalence and mechanisms of this potentially fatal complication.
Introduction Aortic valve replacement (AVR) is the second most commonly performed procedure in cardiac surgery in the United Kingdom (http://bluebook.scts.org/). It remains the gold standard for treating symptomatic severe aortic stenosis. The coronary ostia are in close proximity to the aortic valve and are at risk of compromise as a result of AVR,1 with myocardial infarction and death as possible sequelae. The prevalence of this complication and its relationship to hospital mortality has not been fully investigated, with only a few reported cases of coronary ostial blockage after AVR.1–4 We sought to review the autopsy records of patients who died in hospital after AVR in order to
Patients and methods Prospectively collected clinical and autopsy data of patients undergoing AVR with or without concomitant
Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK Corresponding author: Shakil Farid, MRCS, Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK. Email: [email protected]
Downloaded from aan.sagepub.com at Freie Universitaet Berlin on May 14, 2015
XML Template (2015) [16.2.2015–3:40pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/150009/APPFile/SG-AANJ150009.3d
(AAN)
[1–8] [PREPRINTER stage]
2
Asian Cardiovascular & Thoracic Annals 0(0)
procedures in a single institution between January 1998 and March 2013 were retrospectively reviewed. A small number of other aortic valve procedures (such as valve inspection, valve resuspension, and complete root replacement with coronary reimplantation) were excluded because impingement on the coronary ostia by AVR was not an issue. Clinical and procedural data were obtained from the hospital clinical database system. Reports of the autopsy findings in patients who died in hospital after AVR were reviewed by two investigators to determine whether there was evidence of coronary ostial compromise and to make an informed judgment about whether any such ostial compromise contributed to the fatal outcome. The continuous variables are described as mean standard deviation. The categorical variables are described as percentages. Student’s unpaired t test was used to compare continuous variables, while the chi-square test or Fisher’s exact test was used to describe differences in categorical variables. A p value
(AAN)
[1–8] [PREPRINTER stage]
Original Article
Coronary ostial compromise in aortic valve replacement: An avoidable complication
Asian Cardiovascular & Thoracic Annals 0(0) 1–8 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315573105 aan.sagepub.com
Shakil Farid, Aravinda Page, Neil Howell, Martin Goddard, Yasir Abu-Omar, David P Jenkins and Samer AM Nashef
Abstract Background: We sought to determine the incidence of hospital death due to surgical compromise of the coronary ostia in aortic valve replacement. The mechanism of coronary ostium blockage was also investigated. Methods: A retrospective review was conducted of prospectively collected clinical data and autopsy findings in 322 patients who died in hospital after aortic valve replacement with or without concomitant procedures in a single institution from January 1998 to March 2013. Results: Over the 15-year period, more than 17 surgeons performed 7507 aortic valve replacements with or without other procedures. The mean age of the patients was 70.8 11.78 years and 63% were male. Bioprosthetic valves were used in 75%, mechanical valves in 24.7%, and homografts in only 0.3%. Early mortality for all patients (combined, emergency, and redo procedures) was 4.29% (mean logistic EuroSCORE 10.7). There were 322 deaths after procedures involving the aortic valve. Autopsy examinations were carried out in all patients and showed that 3.4% (n ¼ 11) of deaths were at least partly attributed to encroachment on one or both coronary ostia. Causes of ostial compromise included the valve sutures, the valve sewing ring, and the aortotomy suture line. Conclusions: Coronary ostial compromise in aortic valve replacement is a very rare but real problem occurring in at least 0.15% of aortic valve replacements and contributing to or directly causing one in every 29 aortic valve replacement deaths. Surgeons should have a high level of awareness of the risk of this rare but fatal and avoidable complication.
Keywords Aortic valve, coronary stenosis, heart valve diseases, heart valve prosthesis implantation, postoperative complications
investigate the prevalence and mechanisms of this potentially fatal complication.
Introduction Aortic valve replacement (AVR) is the second most commonly performed procedure in cardiac surgery in the United Kingdom (http://bluebook.scts.org/). It remains the gold standard for treating symptomatic severe aortic stenosis. The coronary ostia are in close proximity to the aortic valve and are at risk of compromise as a result of AVR,1 with myocardial infarction and death as possible sequelae. The prevalence of this complication and its relationship to hospital mortality has not been fully investigated, with only a few reported cases of coronary ostial blockage after AVR.1–4 We sought to review the autopsy records of patients who died in hospital after AVR in order to
Patients and methods Prospectively collected clinical and autopsy data of patients undergoing AVR with or without concomitant
Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK Corresponding author: Shakil Farid, MRCS, Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK. Email: [email protected]
Downloaded from aan.sagepub.com at Freie Universitaet Berlin on May 14, 2015
XML Template (2015) [16.2.2015–3:40pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/150009/APPFile/SG-AANJ150009.3d
(AAN)
[1–8] [PREPRINTER stage]
2
Asian Cardiovascular & Thoracic Annals 0(0)
procedures in a single institution between January 1998 and March 2013 were retrospectively reviewed. A small number of other aortic valve procedures (such as valve inspection, valve resuspension, and complete root replacement with coronary reimplantation) were excluded because impingement on the coronary ostia by AVR was not an issue. Clinical and procedural data were obtained from the hospital clinical database system. Reports of the autopsy findings in patients who died in hospital after AVR were reviewed by two investigators to determine whether there was evidence of coronary ostial compromise and to make an informed judgment about whether any such ostial compromise contributed to the fatal outcome. The continuous variables are described as mean standard deviation. The categorical variables are described as percentages. Student’s unpaired t test was used to compare continuous variables, while the chi-square test or Fisher’s exact test was used to describe differences in categorical variables. A p value
