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In recent years, there has been a great deal of progress in coronary artery surgery, nonsurgical treatment of coronary artery disease, and the surgical treatment of valvular heart disease. As thoroughly described in previous chapters, surgery on the beating heart has become commonplace. Interventional therapies for coronary artery obstruction have extended to multivessel disease and continue to change the number and the nature of patients referred for bypass surgery. The options for treatment of valvular disease have continued to expand with advances in techniques for repair of aortic and mitral valves, as well as increases in the choices of valve type for replacement. Techniques for aortic valve replacement on the beating heart via a retrograde transvascular or transapical approach are now under investigation. Other areas of rapidly growing interest are surgical treatment of atrial arrhythmias and the surgical approach to the failing ventricle in dilated ischemic cardiomyopathy. Some of these topics are discussed in other chapters. All are issues that the surgeon must consider when planning a strategy for the treatment of the patient with combined valvular and coronary artery disease. More patients are now presenting with increasingly complex pathology. It is less often that the surgeon sees a patient with simple aortic stenosis and proximal coronary artery disease. Rather, that patient now may have been managed with more aggressive medical therapy or even catheter interventions, and is referred at an older age and is sicker, with more diffuse disease, arrhythmias, and worsening ventricular function. As a result those patients who present for surgery have a higher-risk profile than was previously the case, and may require a more flexible and thoughtful approach.

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The interaction between the pathophysiologies of valvular heart disease and coronary artery disease is complex. Valvular heart disease alters ventricular function. Coronary artery disease may have an additional impact because of its potential to affect ventricular morphology and physiology. In addition to decreases in contractile strength, regional myocardial infarction may lead to distortion of ventricular shape with resulting effects not only on ventricular function, but also on mitral valve performance. In patients with valvular heart disease, coronary obstructions may be symptomatic or asymptomatic, but the decision to intervene surgically is often made regardless of the presence of symptoms and in order to have a positive effect on the pathophysiology of both diseases.

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Under most circumstances, surgeons attempt to treat both valvular and coronary artery diseases simultaneously. At the least, this makes for a longer and more complicated operation with longer myocardial ischemia times. Because of this, combined coronary artery and valve operations usually have a higher risk for early and late mortality than operations for isolated valvular heart disease (Fig. 48-1). This complexity increases the need for careful preoperative assessment of myocardial function and an understanding of the impact on ventricular function of the changing afterload and preload associated with valve surgery. Therefore, in adult patients with combined valvular and ischemic heart disease, the assessment of intrinsic ...

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