CABG surgery or CABG/AVR?

A 60-year-old man with three-vessel coronary artery disease and a normal ejection fraction presented with unstable angina. At the time of left-sided heart catheterization, a calcified aortic valve was noted. Peak-to-peak transaortic valve gradient during catheterization was 28 mm Hg. A subsequent echocardiogram before surgery confirmed the findings of the aortic valve, and a peak transaortic valve gradient of 40 mm Hg was calculated. The patient had never had an echocar-

diogram before. Based on Figure 2 in “Coronary artery bypass graft surgery in patients with mild or moderate aortic stenosis,” a concomitant CABG/AVR is recommended for this patient. His relatively young age makes progression to symptomatic aortic stenosis a realistic probability, and therefore prophylactic replacement of the valve is recommended. Using the same graph, you can see that an 80-year-old patient with the same gradient should undergo CABG surgery alone using our data.

Additional data that would be useful in making a recommendation for CABG surgery alone versus CABG/

AVR is the rate of progression of aortic stenosis. If the patient described had a previous echocardiogram and his aortic stenosis was known to be stable (progressing at 3 mm Hg/year or less), the model would suggest superior survival by undergoing CABG surgery alone. Clinical assessment of his comorbidities and life expectancy is important as well.