Coronary artery bypass grafting added to surgical aortic valve replacement in octogenarians.

It is in vain to accomplish by several means what can be done in a few. William of Ockham

The most common valvular heart disease is degenerative aortic stenosis (AS), while the most common cardiac disease is coronary artery disease (CAD) [1, 2], and their prevalence is continuously growing. When both are present, a double intervention can be carried out by the surgical means of coronary artery bypass grafting (CABG) and surgical aortic valve replacement (SAVR), or percutaneous coronary intervention (PCI) plus transcatheter aortic valve implantation (TAVI, also called transcatheter aortic valve replacement) [1, 2]. Notably, treatment for AS is mainly indicated for severe AS in symptomatic patients [3]. Furthermore, these guidelines give recommendations also for the combined treatment of CAD and AS [3].

A recent meta-analysis by Gallingani et al. [4] aimed at addressing the complex conundrum of combined surgical treatment of CAD and AS. The primary aim of this work was to compare the long-term survival of CABG added to SAVR and isolated SAVR (i-SAVR) in patients older than 80 years. A total of 16 retrospective studies were included with a total of 5,382 patients (i-SAVR 2,568, CABG + SAVR 2,814), and the mean follow-up was 5.1 years. Despite some evidence of clinical and statistical heterogeneity, long-term survival was not different between the 2 populations, whereas early mortality seemed higher in patients undergoing CABG + SAVR in comparison to the i-SAVR group. Focusing on postoperative complications, the only meaningful difference was that patients undergoing i-SAVR showed more prolonged mechanical ventilation. Even if SAVR is considered safe in octogenarians, some complications are frequent, and the same risks may apply to CABG [5-10]. Another issue worth consideration is that in some situations the priority of CABG versus SAVR could differ, and in selected instances, SAVR could be indicated even in patients with moderate AS [11].

Focusing more attentively on postoperative complications, one could argue that it would be safer to use a non-invasive approach such as PCI plus TAVI in octogenarians because of their better safety profile [12]. Indeed, guidelines recommend PCI in patients undergoing TAVI with coronary stenosis >70%. However, even if some data suggest similar outcomes between cardiac surgery and transcatheter interventions, we do not have clear evidence on the best method.

Despite the important findings of Gallingani et al., this work remains limited by the inclusion of retrospective studies, without any randomized trial. Nonetheless, according to pathophysiologic insights, performing simultaneous CABG and SAVR could improve systolic flow, coronary reserve and a myocardial oxygenation, with more favourable outcomes especially in elderly patients, who are clearly frail in many cases.

Conflict of interest: Giuseppe Biondi-Zoccai has consulted for Cardionovum, Crannmedical, Innovheart, Guidotti, Meditrial, Opsens Medical, Replycare, Teleflex and Terumo. All other authors report no conflict of interest.