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.