Background
We compared staged percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) with mitral valve replacement (MVR) in patients with combined single-vessel and rheumatic mitral valve (MV) disease.
Patients and methods
We prospectively evaluated 80 patients with combined single coronary artery (requiring revascularization in non-left anterior descending artery territory) and rheumatic MV disease, who were divided into two groups: group I consisted of 40 patients who underwent staged PCI and MVR 3 months later, and group II consisted of 40 patients who underwent combined CABG (using saphenous venous graft) and MVR. We compared between both groups.
Results
The median aortic cross-clamp and cardiopulmonary bypass times were 44 and 62 min, respectively, for group I versus 60.5 and 82 min, respectively, for group II; the difference between groups was statistically significant. A total of eight (20%) patients in group I needed inotropic support versus 12 (30%) patients in group II, which was not statistically significant. No patients in both groups needed any mechanical support in the form of intra-aortic balloon pump. None of the patients in both groups had intraoperative ECG changes in the form of ischemia or arrhythmias. The median ICU length of stay (h) and hospital length of stay (days) were 39 h and 5.5 days, respectively, for group I versus 56.5 h and 8.5 days, respectively, for group II; the difference between groups was statistically significant. The median blood loss (ml) postoperatively was 925 in group I versus 1075 in group II, which was statistically significant. However, the rate of re-exploration for bleeding did not differ significantly between both groups, with 1one (2.5%) case only in group I versus two (5%) cases in group II, and no postoperative delayed cardiac tamponade was noted in any of the two groups. The postoperative complications for groups I and II were as follows: 0 versus three (7.5%), respectively, regarding prolonged mechanical ventilation (>24 h); 0 versus one (2.5%), respectively, regarding respiratory complications; 0 versus two (5%), respectively, regarding wound infection; 0 versus one (2.5%), respectively, regarding cerebrovascular accidents; and two (5%) versus one (2.5%), respectively, regarding acute kidney injury. There was no statistically significant difference between both groups regarding these previous postoperative complications. None of the patients in both groups died within the first 30 days after surgery. None of the patients in both groups had major cardiac events or Cardiac Care Unit admission. Regional wall motion abnormalities were noted in 15 (37.5%) patients of group I versus 17 (42.5%) patients of group II; all underwent stress ECG, and of them, nine (22.5%) patients in group I versus 11 (27.5%) patients in group II showed positive results and were qualified for diagnostic coronary angiography, which confirmed the need for reoperation for myocardial ischemia/infarction within the first year of follow-up postoperatively in four (10%) patients of group I versus eight (20%) patients of group II. All of these follow-up outcomes showed no significant difference between both groups.
Conclusion
A staged approach of PCI followed by MVR is an alternative to the conventional combined CABG and MVR, can be performed safely in some patients with single coronary artery and MV disease, and is associated with good short-term and follow-up outcomes.