EVALUATION AND TREATMENT OF CORONARY ARTERY DISEASE IN PATIENTS WITH VALVULAR HEART DISEASE

DIAGNOSIS OF CORONARY ARTERY DISEASE
CLASS I
(1) Coronary angiography is indicated before valve surgery (including infective endocarditis) or mitral balloon commissurotomy in patients with chest pain, other objective evidence of ischemia, decreased LV systolic function, history of CAD, or coronary risk factors (including age). Patients undergoing mitral balloon valvotomy need not undergo coronary angiography solely on the basis of coronary risk factors.

(2) Coronary angiography is indicated in patients with apparently mild to moderate valvular heart disease but with progressive angina (Canadian Heart Association functional CLASS II or greater), objective evidence of ischemia, decreased LV systolic function, or overt congestive heart failure.

(3) Coronary angiography should be performed before valve surgery in men aged 35 years or older, premenopausal women aged 35 years
or older who have coronary risk factors, and postmenopausal women.

CLASS IIa
(1) Surgery without coronary angiography is reasonable for patients having emergency valve surgery for acute valve regurgitation, aortic root disease, or infective endocarditis.

CLASS IIb
(1) Coronary angiography may be considered for patients undergoing catheterization to confirm the severity of valve lesions before valve surgery without pre-existing evidence of CAD, multiple coronary risk factors, or advanced age.

CLASS III
(1) Coronary angiography is not indicated in young patients undergoing nonemergency valve surgery when no further hemodynamic assessment by catheterization is deemed necessary and there are no coronary risk factors, no history of CAD, and no evidence of ischemia.

(2) Patients should not undergo coronary angiography before valve surgery if they are severely hemodynamically unstable.

TREATMENT OF CORONARY ARTERY DISEASE AT THE TIME OF AORTIC VALVE REPLACMENT
CLASS I
(1) Patients undergoing AVR with significant stenoses (greater than or equal to 70% reduction in luminal diameter) in major coronary arteries should be treated with bypass grafting.

CLASS IIa
(1) In patients undergoing AVR and coronary bypass grafting, use of the left internal thoracic artery is reasonable for bypass of stenoses of the left anterior descending coronary artery greater than or equal to 50% to 70%.

(2) For patients undergoing AVR with moderate stenosis (50% to 70% reduction in luminal diameter), it is reasonable to perform coronary bypass grafting in major coronary arteries.

AORTIC VALVE REPLACEMENT IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS SURGERY
CLASS I
(1) AVR is indicated in patients undergoing CABG who have severe AS who meet the criteria for valve replacement

CLASS IIa
(1) AVR is reasonable in patients undergoing CABG who have moderate AS (mean gradient 30 to 50 mm Hg or Doppler velocity 3 to 4 m per second).

CLASS IIb
(1) AVR may be considered in patients undergoing CABG who have mild AS (mean gradient less than 30 mm Hg or Doppler velocity less than 3 m per second) when there is evidence, such as moderate-severe valve calcification, that progression may be rapid.



JACC Vol. 52, No. 13, 2008
September 23, 2008: e1-142