SAN DIEGO – More and more patients with congenital heart disease are surviving into adulthood, resulting in a growing number of operations performed to repair adult congenital heart disease (ACHD). Many of these patients also have atherosclerotic coronary artery disease that may need to be addressed at the time of ACHD surgery, but data on the prevalence of coronary artery disease in this population, as well as outcomes after such surgery, are limited.
Dr. John M. Stulak
To address this issue, Dr. John M. Stulak of the Mayo Medical School, Rochester, Minn., and his associates conducted a study of 122 patients (77 male) who underwent concomitant coronary artery bypass grafting (CABG) for atherosclerotic coronary artery disease (CAD) at the time of ACHD repair. Dr. Stulak presented the results at the annual meeting of the Society of Thoracic Surgeons.
Dr. Stulak noted that, based on his findings, "Concomitant CABG may be required at the time of repair of ACHD. Disease of the LAD [left anterior descending coronary artery] is most common, and survival is higher when a LIMA [left internal mammary artery] graft is used. Late functional outcome is good with a low incidence of late angina, MI, or the need for percutaneous coronary intervention."
The patients, mean age 64 years, underwent surgery between February 1972 and August 2009. A total of 25% had angina, 6% had prior myocardial infarction, and 5% had undergone percutaneous intervention previously.
The most common primary cardiac diagnoses were secundum atrial septal defect (ASD) in 60%, Ebstein anomaly in 11%, partial anomalous pulmonary venous connection (PAPVC) in 7%, and ventricular septal defect (VSD) in 6%. A total of 17% of the patients had a prior cardiac operation.
The most common operations included ASD repair in 64%; tricuspid valve surgery (11%), pulmonary valve surgery (8%), VSD repair (8%), and PAPVC repair (7%).
A single bypass graft was performed in 69 patients, 2 grafts in 32 patients, 3 grafts in 14 patients, 4 grafts in 5 patients, and 5 grafts in 2 patients.
The LIMA was used in 57 of 82 patients (70%) with LAD disease.
The median follow-up was 6 years and was available for 111 patients. During that time, recurrent CAD was reported in 9 patients (8%); 8 patients (7%) had angina, and 5 (4%) had an MI. Six (5%) patients underwent intervention. All but 11 patients achieved NYHA functional class 1 or 2.
The overall survival observed was 76% at 5 years, 56% at 10 years, and 33% at 15 years. In those patients with LAD disease, 10-year survival was significantly higher when LIMA was used (66% vs. 36%).
Dr. Stulak added in an interview that although awareness of concomitant CAD in this population is growing, there are no firm recommendations on when to evaluate individual patients for the disease.
In addition, he said, the importance of this study is not only to increase appreciation for the potential need for CABG during ACHD repair, but to stress that each treatment approach should be individualized whether it is conventional CABG, off-pump CABG, or a staged hybrid technique with percutaneous coronary intervention for CAD.
Dr. Stulak and his colleagues reported that they had no disclosures.