Excess mortality due to coronary artery disease after valve surgery. Secular trends in valvular regurgitation and effect of internal mammary artery bypass

During the 1980s, mortality from coronary artery disease (CAD) decreased markedly in the United States. This raises the question of whether a parallel decrease occurred in excess mortality due to CAD in patients undergoing surgical correction of valvular regurgitation. Survival of 752 patients (age, 64 +/- 13 years) with isolated left-sided valvular regurgitation operated on from 1980 to 1991 was analyzed. Of 242 patients with CAD (stenosis > or = 70%), 208 had coronary artery bypass grafting. Multivariate analysis identified CAD as an independent predictor of operative mortality (odds ratio [OR] = 2.35, P = 0.012), overall (hazard ratio [HR] = 1.65, P < 0.0001) and late mortality (HR = 1.57, P = 0.0006), and postoperative congestive heart failure (HR = 2.35, P = 0.0001). Comparison of patients operated on in 1980 to 1985 with those operated on in 1986 to 1991, excess of operative, overall, and late mortality and postoperative congestive heart failure (adjusted for age and gender) related to associated CAD did not decrease significantly (P = 0.23, P = 0.64, P = 0.90, and P = 0.61, respectively). Overall survival was better for patients receiving an internal mammary artery graft than those receiving vein grafts only (HR = 0.57, P = 0.011). In contrast to the secular trend for decreased mortality from CAD, excess mortality related to associated CAD after surgery for valvular regurgitation has not decreased. Internal mammary artery grafts were associated with improved outcome. In patients with valvular regurgitations, these results support continued active search of associated CAD, wide use of internal mammary artery graft, and vigorous efforts for secondary prevention of complications of CAD.