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Cardiac bypass and valve surgery 

Cardiac bypass and valve surgery

Chapter:
Cardiac bypass and valve surgery
Author(s):

Graham Cooper

DOI:
10.1093/med/9780199204854.003.161307_update_002

Update:

New chapter including valve surgery and peroperative assessment of patients for cardiac surgery, includes content from retired Chapter 16.13.8.

Updated on 29 Oct 2015. The previous version of this content can be found here.
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date: 29 April 2017

Coronary artery bypass grafting (CABG)—the two main indications for are for relief of symptoms, usually angina and/or breathlessness, that persist even with optimal medical therapy (OMT), and/or prognosis. There is a prognostic benefit of CABG in patients with large volumes of ischaemia (i.e. affecting >12% of the ventricular mass), and the benefit of revascularization increases with increasing volumes of ischaemia. The overall mortality for elective CABG in the United Kingdom is around 1% and has continued to fall over the last decade despite an increasingly adverse risk profile of patients undergoing surgery. In randomized trials and large propensity-matched cohort registries CABG, in comparison to percutaneous coronary intervention (PCI) even with drug-eluting stents, has been shown to improve survival and to reduce the subsequent risk of myocardial infarction and recurrent angina. Approximately 80% of patients are alive a decade after surgery of whom around 70% are still free from angina.

Valve surgery—this is primarily performed for patients with severe valvular disease and symptoms. Indications also include deteriorating ventricular function and the requirement for coronary artery surgery in patients with coexistent valve disease. Mitral valve repair is a highly successful procedure in patients with nonrheumatic valvular regurgitation and is associated with an excellent long-term survival. Aortic valve disease is usually treated with aortic valve replacement. A range of biological and mechanical valves are available for valve surgery, with no difference in outcomes between mechanical and biological valves in respect of mortality, prosthetic valve endocarditis, or thromboembolism, but biological valves have a higher rate of reoperation and the haemodynamic profiles of the biological and newer mechanical valves are similar. Biological valves are particularly attractive for elderly patients in whom anticoagulation is deemed high risk, and now the commonest type of valves implanted worldwide. Patients with aortic stenosis may also be considered for transcatheter valve intervention (TAVI) when the risks of conventional surgery are high. The indications for TAVI for aortic stenosis are likely to expand significantly as the technique develops.

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