Although mortality for surgery combining revascularization and cardiac valve replacement can be as high as 1 in 5, the rate was only 1 in 26 when angioplasty was done before valve replacement, according to an article in the January 4th issue of the Journal of the American College of Cardiology.

“This is one of the futures of cardiovascular interventions,” said John G. Byrne, MD, lead author of the study. “Our intuition was that it would be better, but we were surprised it was that much better. There was a predicted operative risk of 22 percent with the valve and bypass surgery, and we dropped that down to about 4 percent with the staged approach of angioplasty followed by valve replacement surgery.”

With the aging of the population, more and more patients may present with disease of both the heart valves and coronary arteries, increasing the impact of these differing percentages.

The study involved a retrospective review of the medical records of 26 consecutive patients who underwent angioplasty followed by valve surgery from September 1997 to August 2003. The decision to use the two-stage “hybrid” approach was made by each patient’s cardiologist and surgeon. There was no control group in the study.

The patients were very sick. Many had diabetes, lung disease, kidney failure, or other health problems. Close to a third were on a ventilator, and more than 40 percent had just had an acute myocardial infarction. Based on their clinical characteristics, the researchers predicted it was likely that more than 1 of 5 would have died during conventional combination bypass and valve replacement surgery.

“However, the study involved small numbers. If we had had 1 more death in the study group, the operative risk would have been 8 percent instead of 4 percent, so the results must be kept in perspective, recognizing the small number of patients,” Byrne said.

Survival at 1, 3, and 5 years was 78 percent, 56 percent, and 44 percent, respectively. According to Byrne, these long-term survival rates are similar to those following conventional bypass and valve surgery. The patients in the study did suffer more bleeding and needed more transfusions than would have been expected with conventional surgery.

Byrne noted that almost all of patients were given stents. He said that medication with clopidogrel (Plavix^®) to reduce the risk of blood clots forming in the stents probably contributed to increased bleeding observed during the valve surgery.

At the time of the study, patients underwent angioplasty in cardiac catheterization laboratories; a few days later they underwent valve replacement surgery in an operating room. Some hospitals are already building hybrid procedure suites in order to do both procedures without having to wait or move the patient.

David S. Bach, MD, who was not connected with this study, noted that it was a retrospective look at only a small number of unusually sick patients.
“As a result, the estimated risk for combined surgery in this study was very high, which would have tended to exaggerate the benefit of the hybrid approach,” Bach said.

Nevertheless, he said the results suggest the hybrid approach is an attractive option for certain patients. He said it is already being applied more broadly.
“By extension, a similar staged approach may be reasonable in other, less high-risk, cases. At the University of Michigan, we employ such a staged approach for some patients in a non-emergent setting,” he said.