puravida1
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If a patient with aortic stenosis that requires valve replacement has CAD requiring CABG or PCI, which is done first? the valve replacement or the CABG/PCI stent????
thanks!
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| farnsworth
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one session: valve replacement + CABG
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| puravida1
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well, I saw a question don't remember if it was UWorld or qbank, but you had to pick in between them, don`t remember the answer, but I'm sure they had one before the other.
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| farnsworth
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it depends:
what is more severe: aortic stenosis? coronary artery disease? does the patient need to undergo CABG or PCI?
So the question can't be answered with the given information.
In general it is more difficult/demanding to do a re-thoracotomy, so if the patient needs CABG and aortic valve replacement it makes sense to do this in one session (especially if the CAGB can't be done as OPCAB/MIDCAB procedures, meaning you have to cannulate a heart/vessels that has previously been cannulated)
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| docnikki
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thanks farnworth...you look like a very smart cardiologist!
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| puravida1
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ok, agree on that, but what if no criteria are met for CABG and you only need a PCI, does that go first or do you do the valvular repair before?
thanks!
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| farnsworth
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If you do a PCI before aortic valve replacement, you have to keep in mind, that the patient has an increased risk of bleeding. After PCI the patient usually takes aspirin (lifelong!), GIIb/IIIa antagonist (e. g. abciximab, eptifibatide), and a ADP-receptor antagonist (e. g. clopidogrel). These drugs cannot be as easily antagonized as heparin (protamine sulfate), so you should considering discontinuation of ADP- and GIIb/IIIa-receptor antagonists to reduce bleeding tendencies (sternotomy for CABG!!!). This puts the patient at risk for stent thrombosis (especially when DES (drug eluting stents) are used). Some people recommend using bare metal stents (BMS), and postpone elective surgery until clopidrogel is discontinued (3-4 mo for BMS, 6-12 mo (!) for DES).
The risk of perioperative complications is the highest in the first two weeks after PCI (arrhythmia, stent thrombosis, ischemia, myocardial infarction), and even if surgery is scheduled after the first 2 weeks you should discuss the risks and complications with the patient. However, data on the timing of elective surgery after PCI is scarce.
But back to your question, you might check this article
http://www.sciencedirect.com/science?_ob=ArticleU...
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| puravida1
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waw,,,,thanks!
great feedback!
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