Methods
The study was a prospective comparative review, of 2 years duration, of
80 patients with combined single coronary artery (requiring
revascularization in non-LAD territory) and rheumatic MV disease,
divided into two groups; Group I consisting of 40 patients who underwent
staged PCI, and mitral valve replacement 3 months later, and Group II
consisting of 40 patients who underwent combined CABG (using saphenous
venous graft) and mitral valve replacement. The study centers were
Cardiothoracic Surgery Department of Ain Shams University Hospitals, and
National Heart Institute (NHI). PCI was done at Cardiology Department of
Ain Shams University Hospitals, and National Heart Institute (NHI).
Included were patients with combined single vessel and mitral valve
disease, of age between 35 and 60 years old. Excluded were patients with
Ejection Fraction (EF) less than 45%, concomitant aortic or tricuspid
valve disease requiring surgery, concomitant congenital heart disease
requiring surgical correction, redo cardiac surgery, acute coronary
syndrome requiring primary PCI together with mitral valve disease,
renal/hepatic failure, Chronic Obstructive Pulmonary Disease (COPD) or
other respiratory disease, any neurological deficit or previous
cerebrovascular event, or hematological disorders.
In all patients, the coronary and valvular lesions were documented by
diagnostic catheterization and echocardiography, respectively. Patients
were selected to undergo a hybrid approach after a comprehensive Heart
Team evaluation. Baseline variables, operative characteristics and
outcomes, and major adverse cardiovascular events during the follow-up
period were analyzed using our institutional medical records, outpatient
surgical and cardiology office visits, and a follow-up survey at 3-month
intervals within the first postoperative year.
All patients were clinically stable for both PCI and the operation.
Preoperative medication regimens were similar. Once the treatment plan
was established, the interventional cardiologist proceeded with PCI of
the significant lesion in the native vessel. Drug-eluting stents were
placed in all of Group I patients. A loading dose of 600 mg clopidogrel
and 325 mg aspirin was administered at the time of stent placement,
followed by clopidogrel 75 mg daily and aspirin 81 to 325 mg daily
thereafter (dual antiplatelet therapy). Management of antiplatelet
therapy between the PCI and the operation was at the discretion of the
interventional cardiologist. The patients had their antiplatelet agents
stopped 5 days before surgery. All patients resumed their antithrombotic
regimen within 24 to 48 hours after surgery, which comprised of single
antiplatelet (clopidogrel 75 mg daily) and an oral anticoagulant dose
adjusted according to target International Normalized Ratio (INR),
because of the mechanical mitral valve prosthesis inserted in all
patients.
In all patients, standard median sternotomy was performed, followed by
inverted T-shaped pericardiotomy, Aorto-bicaval cannulation, conduction
of cardiopulmonary bypass, and application of aortic cross-clamp. Warm
blood antegrade cardioplegia was given. Mitral valve was accessed
through left atriotomy via Sondergaard’s groove, preservation of the
posterior leaflet was done, and the mechanical mitral prosthesis
inserted using 2-0 interrupted Ethibond sutures with pledgets sitting on
the atrial surface of the mitral valve. Closure of left atrium, deairing
through aortic root vent, and removal of aortic cross-clamp. Weaning off
bypass, hemostasis, and anatomical closure in layers. In group II
patients, the distal and proximal anastomoses using 7-0 and 6-0 Prolene
sutures, respectively, were done in addition to the previous steps of
mitral valve replacement, using the saphenous venous graft harvested
simultaneously with the median sternotomy at the start of the operation.
The intraoperative variables prospectively assessed as per our study
included total cardiopulmonary bypass time, total cross-clamp time, the
need for inotropic support, and ECG changes in the form of ischemia or
arrhythmias. The postoperative outcomes included bleeding,
cerebrovascular accidents, renal failure, respiratory complications,
duration of mechanical ventilation, duration of ICU stay, wound
infection, duration of hospital stay, and 30-day mortality. All patients
underwent postoperative routine trans-thoracic echo (TTE) follow up upon
discharge, after 3 months, 6 months, and 1 year, postoperative stress
ECG and/or coronary angiography if needed. The follow-up outcomes
included major cardiac events or CCU admission within first year, and
the need for reoperation for myocardial infarction or ischemia within
first year.