Should coronary arteriography be performed routinely before valve replacement?

The implication that coronary atherosclerosis is a common cause of complications and death after prosthetic heart valve replacement has resulted in the performance of routine preoperative coronary arteriography in many clinics. A review of 4 years' experience with such studies at the University of Oregon Medical School Hospital indicates that patients with significant coronary obstruction in conjunction with valvular heart disease always had angina pectoris. None of the postoperative deaths or complications were due to demonstrable coronary artery disease without preexisting angina. It is likely that the increased cardiac work load imposed by valvular heart disease increases myocardial oxygen demands. Significant coronary atherosclerosis is therefore unlikely to remain asymptomatic. Coronary arteriography may be safely omitted before valve replacement in many patients with increased myocardial work who have no symptoms of ischemic heart disease, and who lack risk factors known to increase its incidence.