When is concomitant aortic valve replacement indicated in patients with mild to moderate stenosis undergoing coronary revascularization?

Mild to moderate aortic stenosis is a common finding in patients presenting for coronary artery bypass grafting (CABG), and its management is controversial. However, review of available data suggests a surgical strategy for these patients. Recent data demonstrate that 1) progression of aortic stenosis is more rapid in those with leaflet calcification; 2) the addition of aortic valve replacement to CABG in patients with mild to moderate stenosis does not increase hospital mortality when compared with bypass surgery alone; 3) hospital mortality for aortic valve replacement after previous bypass surgery has declined in recent years; 4) aortic valve replacement places the patient at risk for prosthesis-related complications; 5) the limited 10-year survival (competing risk of death) leaves only a minority of individuals with mild aortic stenosis alive and eligible for aortic valve replacement 10 years after bypass surgery; and 6) combined aortic valve replacement and CABG confers a survival benefit in those with moderate aortic stenosis but not in those with mild aortic stenosis. Therefore, in the coronary artery bypass patient with moderate aortic stenosis, leaflet calcification, and life expectancy greater than 5 years, concomitant aortic valve replacement is advised. In contrast, aortic valve replacement is rarely indicated in those with mild aortic stenosis.