What is the follow-up treatment after open heart surgery for aortic valve replacement and Coronary Artery Bypass Grafting (CABG) to Right Coronary Artery (RCA)?

From the Guidelines

After open heart surgery for aortic valve replacement and coronary artery bypass grafting (CABG) to the right coronary artery (RCA), follow-up treatment should prioritize lifelong follow-up by a cardiologist, with clinical assessment performed yearly or as soon as possible if new cardiac symptoms occur, as recommended by the 2017 ESC/EACTS guidelines for the management of valvular heart disease 1. The follow-up treatment plan should include:

• Cardiac rehabilitation, which is recommended for all patients after CABG, with the referral ideally performed early postoperatively during the surgical hospital stay, as stated in the 2015 scientific statement from the American Heart Association 1
• Medication management, including anticoagulants such as warfarin (typically 2-5mg daily) if a mechanical valve was placed, or aspirin (81mg daily) for tissue valves, as well as beta-blockers like metoprolol (25-100mg twice daily) and statins such as atorvastatin (20-80mg daily) to manage cholesterol levels
• Wound care, including keeping the incision clean and dry, watching for signs of infection, and sternal precautions (avoiding lifting more than 10 pounds for 6-8 weeks)
• Regular medical appointments, typically occurring at 1-2 weeks, 4-6 weeks, 3 months, 6 months, and annually thereafter, with regular echocardiograms to monitor valve function, as recommended by the 2017 ESC/EACTS guidelines for the management of valvular heart disease 1
• Secondary prevention measures, including the administration of antiplatelet agents, beta-blockers, angiotensin-converting enzyme inhibitors (ACE-I), statins, and fatty acids, which have been identified as independent predictors of survival after CABG, as stated in the 2013 European Heart Journal article on coronary artery bypass grafting 1
• Lifestyle interventions, such as education and counselling on eliminating risk factors, healthy food choices, stress relief, and exercise, which provide substantial benefit for patients, as reported in the 2013 European Heart Journal article on coronary artery bypass grafting 1 The goal of these measures is to promote healing, prevent complications, and ensure the long-term success of the surgery by supporting cardiac function and preventing further coronary disease progression. Key considerations for follow-up treatment include:
• The importance of lifelong follow-up by a cardiologist, as recommended by the 2017 ESC/EACTS guidelines for the management of valvular heart disease 1
• The need for regular clinical assessment and echocardiograms to monitor valve function and detect any potential complications
• The role of medication management in preventing further coronary disease progression and promoting long-term survival
• The importance of lifestyle interventions in reducing risk factors and promoting overall health and well-being.

From the FDA Drug Label

For patients with bioprosthetic valves, warfarin therapy with a target INR of 2.5 (range, 2.0 to 3.0) is recommended for valves in the mitral position and is suggested for valves in the aortic position for the first 3 months after valve insertion. The follow-up treatment after open heart surgery for aortic valve replacement and CABG to RCA may include warfarin therapy with a target INR of 2.5 (range, 2.0 to 3.0) for the first 3 months after valve insertion, as suggested for patients with bioprosthetic valves in the aortic position 2.

• The duration of therapy should be individualized, and anticoagulant therapy should be continued until the danger of thrombosis and embolism has passed.
• The dosage of warfarin sodium tablets must be individualized according to the patient's sensitivity to the drug as indicated by the PT/INR.

From the Research

Follow-up Treatment after Open Heart Surgery

The follow-up treatment after open heart surgery for aortic valve replacement and coronary artery bypass grafting (CABG) to the right coronary artery (RCA) involves several aspects, including medical therapy and monitoring for potential complications.

• Medical Therapy: Studies have shown that medical therapy with renin-angiotensin system (RAS) inhibitors and statins may be beneficial in reducing the risk of major adverse cardiovascular events after surgical aortic valve replacement 3.
• Monitoring for Complications: Patients who have undergone aortic valve replacement and CABG are at risk for various complications, including thromboembolic events, anticoagulant-related hemorrhage, and reoperation 4.
• Long-term Survival: The long-term survival of patients who have undergone aortic valve replacement and CABG is influenced by several factors, including functional class and left ventricular end-diastolic pressure 5.
• Age and Comorbidities: Age and comorbidities, such as heart failure and hyperlipidemia, can also impact the outcome of patients who have undergone aortic valve replacement and CABG 3, 6.
• Surgical Techniques: The surgical technique used for aortic valve replacement and CABG can also impact the outcome, with some studies suggesting that combined procedures may not increase postoperative risk in healthy octogenarians 6.

Specific Considerations

• Aortic Valve Replacement after Previous CABG: Patients who have undergone previous CABG and require subsequent aortic valve replacement are at higher risk for mortality and complications 7.
• Redo CABG with AVR: Redo CABG with AVR is a complex procedure that requires careful consideration of the patient's underlying coronary artery disease and the state of the previously placed bypass conduits 7.