[HSF] Aortic Valve Stenosis and Carotid Stenosis

Thu Jan 24 16:12:11 EST 2008

Thank you for your self honesty.

We started this thread with a patient with both carotid and aortic valve disease. We moved to the finding that that there is no known association between AS and carotid stenosis implying it was not a problem. By your own numbers there is a 5% prevalence of carotid disease with CAD. We presume (at least i do) that with untreated carotid disease for CAB there may be a 5-10% risk of stroke with CAB. This means there is 90-95% chance of no noticeable effect during CAB without treatment of the carotid disease. If we apply even this ratio to your data for series of AS, there is a significantly less than 1% chance that we will see a problem. It is likely less for this population since valvular sclerosis is probably a pathophysiology distinct from atherosclerosis. None of this tells us what to do with the patient in front of us that has both AS and carotid disease. If we propose a different strategy we must then posit why carotid atherosclerosis acts differently
 with AS than without it or conversely why AS is a more an urgent condition than CAD. 

tea

----- Original Message ----
From: "Douville, Chuck" <ecdouville at orclinic.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, January 24, 2008 3:33:06 PM
Subject: RE: [HSF] Aortic Valve Stenosis and Carotid Stenosis

Tea good point, No screening data available to say whether or not it exists in AS in a population study. Perhaps I (we) comfort myself too much with what I do know, rather than what I don't. You always ask good questions and are a thoughtful skeptic on this forum. 

________________________________

From: openheart-l-bounces at lists.hsforum.com on behalf of Tea Acuff
Sent: Thu 1/24/2008 10:41 AM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Aortic Valve Stenosis and Carotid Stenosis

Our world of information or data is an interesting one. I could go off on one of my discourses, but I like it better that we are wrestling with its meaning one on one for a particular. Let me ask you a question(s all related), if I may. What is your intent in using the data in the way that you propose using association as a key? To narrow that open thought, is there a difference in screening populations and assessing a particular patient? I presume for example that you would screen for CAD in a patient with AS even if the association is, as you claim, between CAD and carotids, not AS and carotids. Why AS and CAD, then? Do we use information for only for what it shows or also what it hides?

tea

----- Original Message ----
From: "Douville, Chuck" <ecdouville at orclinic.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, January 23, 2008 10:22:45 PM
Subject: RE: [HSF] Aortic Valve Stenosis and Carotid Stenosis

Hmmm Tea good question. I don't think the association between isolated aortic valve disease and hemodynamically significant carotid stenosis has ever been demonstrated. In contrast, the link between left main CAD and hemodynamically significant carotid disease has been as high as 10% in the Washington University data base from several years past. Thus, I think there is data, and in our own practice we screen CAD patients with left main disease, age over 70 and severe peripheral arterial disease for hemodynamically significant carotid disease.

chuck

________________________________

From: openheart-l-bounces at lists.hsforum.com on behalf of Tea Acuff
Sent: Wed 1/23/2008 8:19 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Aortic Valve Stenosis and Carotid Stenosis

Why would you suggest it? Are you against screening patients with neither known CAD or AS? I could go on but this is enough.

tea

----- Original Message ----
From: "Douville, Chuck" <ecdouville at orclinic.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, January 22, 2008 11:23:00 AM
Subject: RE: [HSF] Aortic Valve Stenosis and Carotid Stenosis

I would suggest that screening carotids in pure aortic valve disease is not indicated, However, Ed's pt had coronary artery disease; it is reasonable to screen elderly pts with coronary disease for concomittant carotid disease. Some, eg Drs. Waering and Kouchoukos at Wash U 12 years ago  or so,  have demonstrated significant improvement in neurologic outcomes with such an aggressive strategy.

________________________________

From: openheart-l-bounces at lists.hsforum.com on behalf of Ani Anyanwu
Sent: Tue 1/22/2008 6:18 AM
To: openheart-l at lists.hsforum.com
Subject: RE: [HSF] Aortic Valve Stenosis and Carotid Stenosis

> possibility of MI is real, but the possibility of permanent cardiac > damage with moderate AS (in the short term) is low. .> Ed Bender, MD

Ed

Ed with an indexed AVA of 0.4, would your patient not qualify as severe AS? I am uncertain really as to the indication for carotid surgery here - is it to reduce risk of perioperative stroke or is it required on its own merit? I am not sure of the wisdom of putting someone with severe AS through two operations before the definitive (life-saving or life-prolonging) one as each procedure places her at risk and I am not sure that the risk and cumulative morbidity of the 3 operations will be less, and the benefit greater, than that of a single operation to replace his aortic valve. In an elderly patient we must not underestimate the impact of multiple surgeries done in quick succession - you accept this yourself when you say you will do the second carotid "when the patient is feeling well and recovered". Sometimes staged candidates never make it to the final definitive procedure (because of complications, death or debilitation). If the same patient required
other non-cardiac surgery, such as a hernia repair, he would not be cleared for that till the AS is fixed - what makes a carotid procedure different that it should be done first?

Personally, I do not see rationale for obtaining the carotid ultrasound in an elderly patient with asymptomatic AS and certainly I would not go operating on the carotids in a patient with severe AS unless indicated by symptoms. I also do not listen for carotid bruits anymore as it is a poor screening test, many patients without bruit have carotid disease,  and it is unclear what to do with the information it yields. I think in the setting of ischemic heart disease there is more literature to support carotid screening but there is a clear disticntion in the natural history of IHD vs aortic stenosis that makes the arguments different. I think part of the bias in management here comes from our tendency to do things (carotid in this instance) because we can. As a cardiovascular surgeon you would feel comfortable doing the carotids and can likely do so with little incremental risk (I have the reverse bias because I am not vascular trained so a reluctance to
intervene in this case and general reluctance to involve another team of surgeons in managing cardiac surgical patients) but can we really say we have the data to support this approach in patients with valvular heart disease?  If you did her aortic valve first, would you still go ahead to fix the carotids?

Ani

> From: ebender001 at charter.net> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Aortic Valve Stenosis and Carotid Stenosis> Date: Mon, 21 Jan 2008 23:07:00 -0600> CC: > > The only difference that I see is that in CAD patients is that the > possibility of MI is real, but the possibility of permanent cardiac > damage with moderate AS (in the short term) is low. Having said that, > I still agree with your sentiments regarding order of procedures. I > can also effectively treat CHF ( a little more lasix, etc) better than > I can treat a stroke (a little more tube feeds).> Ed Bender, MD> > > On Jan 21, 2008, at 10:52 PM, Tea Acuff wrote:> > > We recently did a similar case status post CABG several years ago. I > > did each carotid a couple of days apart and the the patient (who was > > elderly siad uncel and we gave him a week or so prior to redo > > sterntomy for AVR. This is what i do for CAB and carotids also. I > > see no clear difference in the
face of no documented difference.> >> > tea> >> >> > ----- Original Message ----> > From: "Douville, Chuck" <ecdouville at orclinic.com>> > To: OpenHeart-L at lists.hsforum.com> > Sent: Monday, January 21, 2008 10:17:31 PM> > Subject: RE: [HSF] Aortic Valve Stenosis and Carotid Stenosis> >> > Ed interesting question. I personally would stage the carotids, > > about 3 days apart and do the valve shortly thereafter. We have had > > good results with combining urgent carotids with CABG but have no > > experience with your situation. I would stage them because of the > > literature we are all familiar with, no other (better) reason. chuck> >> > ________________________________> >> > From: openheart-l-bounces at lists.hsforum.com on behalf of zzhoumd at pol.net> > Sent: Mon 1/21/2008 8:07 PM> > To: OpenHeart-L at lists.hsforum.com> > Subject: Re: [HSF] Aortic Valve Stenosis and Carotid Stenosis> >> >> >> >> > In a asymptomatic patient, the stroke rate is low whatever you
do > > probably not much of difference either way.> >> > Sent via BlackBerry by AT&T> >> > -----Original Message-----> > From: Edward Bender <ebender001 at charter.net>> >> > Date: Mon, 21 Jan 2008 21:07:47> > To:OpenHeart-L <OpenHeart-L at hsforum.com>> > Subject: [HSF] Aortic Valve Stenosis and Carotid Stenosis> >> >> > I'd be interested in the members' opinions about the following> > patient. She is a 74 year old diabetic patient admitted to an outside> > hospital with chest pain and class 2 heart failure symptoms. She> > underwent echo and cardiac cath showing trivial coronary artery> > disease (50% LAD at most), 50 mmHg gradient across the aortic valve,> > normal LV function. The indexed valve area is 0.4. She underwent> > carotid dopplers due to a bruit. This showed over 80% stenosis in> > both internal carotid arteries. She is left dominant. I repeated the> > cardiac and carotid echos in our hospital and the outside studies are> > supported by our
studies. The outside cath did not include an LV> > gram, and I see no attempt to have crossed the aortic valve.> >> > The patient is a relative of one of our local physicians, and she is> > now an outpatient on appropriate medical therapy. Although I think> > that she will need AVR, I do not think it is an urgent requirement.> > The outside hospital cardiologist said she needed 3 bypasses and an> > aortic valve next week, and that he would have a surgeon come down> > from a major midwestern university to do the operation at their> > hospital (itinerant surgery). Needless to say, after the patient was> > discharged on medical therapy, the local physician took his relative> > out of that hospital system.> >> > I was planning to do a left carotid endarterectomy, followed by a> > right carotid when the patient is feeling well and recovered. Any> > thoughts about doing the aortic valve at the time of the second> > carotid surgery? I do this alot with
coronaries (I think we had> > several discussions about this topic), but have not had the same> > scenario with valvular heart disease in the absence of important> > carotid disease.> >> > Ed Bender, MD> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the > > policies and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> >> >> >> >> > -----Inline Attachment Follows-----> >> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l>
>> > All messages transmitted by the OpenHeart-L are subject to the > > policies and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the > > policies and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and
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