Tsuyoshi Kaneko1, Christina M Vassileva2, Brian Englum3, Sunghee Kim4, Maroun Yammine1, Matthew Brennan5, Rakesh M Suri6, Vinod H Thourani7, Jeffrey P Jacobs8, Sary Aranki9. 1. Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts. 2. Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois. 3. Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina. 4. Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina. 5. Division of Cardiology, Duke University Medical Center, Durham, North Carolina. 6. Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota. 7. Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. 8. Division of Cardiothoracic Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, Florida. 9. Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts. Electronic address: saranki@partners.org.
Abstract
BACKGROUND: Reoperative aortic valve replacement (re-AVR) after previous AVR is a complex procedure involving redo sternotomy and removal of a previous prosthesis. With increasing use of valve-in-valve transcatheter aortic valve replacement for failed aortic bioprostheses, an evaluation of contemporary outcomes of re-AVR in patients with bioprostheses is warranted. METHODS: The study included 3,380 patients from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (July 2011 to September 2013) who underwent elective, isolated re-AVR after a previous AVR. Outcomes in these patients were compared with those of 54,183 patients with isolated primary AVR during the same period. A subgroup analysis of explanted bioprostheses in re-AVR (previous bioprosthetic valve: n = 2,213) was performed. RESULTS: Re-AVR patients were younger (66 vs 70 years, p < 0.001) compared with primary AVR patients. Re-AVR was associated with higher operative mortality (4.6% vs 2.2%, p < 0.0001), composite operative mortality and major morbidity (21.6% vs 11.8%, p < 0.0001), postoperative stroke (1.9% vs 1.4%, p = 0.02), postoperative aortic insufficiency mild or greater (2.8% vs 1.7%, p < 0.0001), pacemaker requirement (11.0% vs 4.3%, p < 0.0001), and vascular complications (0.06% vs 0.01%, p = 0.04). For the explanted previous bioprosthetic valve group, operative mortality was 4.7%, composite outcome was 21.9%, stroke rate was 1.8%, and pacemaker requirement was 11.5%. CONCLUSIONS: Re-AVR is now performed with an acceptable operative mortality, which is higher than primary AVR. The overall incidence of stroke, vascular complication, and postoperative aortic insufficiency was low although higher than primary AVR. These results may serve as a benchmark for future analysis of valve-in-valve transcatheter aortic valve replacement and may have an effect on future choice of transcatheter aortic valve replacement vs re-AVR.
BACKGROUND: Reoperative aortic valve replacement (re-AVR) after previous AVR is a complex procedure involving redo sternotomy and removal of a previous prosthesis. With increasing use of valve-in-valve transcatheter aortic valve replacement for failed aortic bioprostheses, an evaluation of contemporary outcomes of re-AVR in patients with bioprostheses is warranted. METHODS: The study included 3,380 patients from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (July 2011 to September 2013) who underwent elective, isolated re-AVR after a previous AVR. Outcomes in these patients were compared with those of 54,183 patients with isolated primary AVR during the same period. A subgroup analysis of explanted bioprostheses in re-AVR (previous bioprosthetic valve: n = 2,213) was performed. RESULTS: Re-AVR patients were younger (66 vs 70 years, p < 0.001) compared with primary AVR patients. Re-AVR was associated with higher operative mortality (4.6% vs 2.2%, p < 0.0001), composite operative mortality and major morbidity (21.6% vs 11.8%, p < 0.0001), postoperative stroke (1.9% vs 1.4%, p = 0.02), postoperative aortic insufficiency mild or greater (2.8% vs 1.7%, p < 0.0001), pacemaker requirement (11.0% vs 4.3%, p < 0.0001), and vascular complications (0.06% vs 0.01%, p = 0.04). For the explanted previous bioprosthetic valve group, operative mortality was 4.7%, composite outcome was 21.9%, stroke rate was 1.8%, and pacemaker requirement was 11.5%. CONCLUSIONS: Re-AVR is now performed with an acceptable operative mortality, which is higher than primary AVR. The overall incidence of stroke, vascular complication, and postoperative aortic insufficiency was low although higher than primary AVR. These results may serve as a benchmark for future analysis of valve-in-valve transcatheter aortic valve replacement and may have an effect on future choice of transcatheter aortic valve replacement vs re-AVR.
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