Coronary artery bypass surgery and minor aortic stenosis--to replace or not to replace?

Seven patients with a mean age of 65 years (range 50-76 years) who had minor aortic valve gradients (less than 25 mmHg) at preoperative cardiac catheterization underwent coronary artery bypass surgery without aortic valve surgery, but required a second operation for aortic valve replacement between five and nine years later because of symptomatic aortic valve stenosis with a valve gradient which had increased to between 60 and 100 mmHg. Serial hemodynamic observations in patients with aortic stenosis have demonstrated that the rate at which stenosis progresses is widely variable. However, replacement of aortic valves at the time of initial coronary artery surgery may subject the patients to an increased risk of operative mortality and prosthetic valve-related complications. On the other hand, the patient may miss the opportunity to obtain maximum benefit from valve replacement before deterioration of left ventricular function, particularly in the presence of coronary artery disease, and there are also the risks of resternotomy. We are currently inclined to replace the aortic valve in coronary patients with asymptomatic aortic stenosis, but our experience is not sufficient to draw final conclusions and the relevant literature does not provide a clear guidance. The aim of this publication is to expose this dilemma.