Adult: Aortic Valve
The decreasing risk of reoperative aortic valve replacement: Implications for valve choice and transcatheter therapy

Accepted for the 100th Annual Meeting of The American Association for Thoracic Surgery.
https://doi.org/10.1016/j.jtcvs.2022.02.052Get rights and content

Abstract

Objective

Increasing use of bioprostheses for surgical aortic valve replacement (SAVR) in younger patients, together with wider use of transcatheter aortic valve replacement, necessitates understanding risks associated with surgical valve reintervention. Therefore, we sought to identify risks of reoperative SAVR compared with those of primary isolated SAVR.

Methods

From January 1980 to July 2017, 7037 patients underwent nonemergency isolated SAVR, with 753 reoperations and 6284 primary isolated operations. These 2 groups were propensity score-matched on 46 preoperative variables, yielding 581 patient pairs for comparing outcomes.

Results

Among propensity score-matched patients, aortic clamp time (median 63 vs 52 minutes; P < .0001), cardiopulmonary bypass time (median 88 vs 67 minutes; P < .0001), and postoperative stay (median 7.1 vs 6.9 days; P = .003) were longer for reoperative SAVR than primary isolated SAVR. Hospital mortality after reoperative SAVR decreased from 3.4% in 1985 to 1.3% in 2011, similar to that of primary isolated SAVR. Occurrence of stroke, deep sternal wound infection, and new renal dialysis was similar. Blood transfusion (67% vs 36%; P < .0001) and reoperations for bleeding/tamponade (6.4% vs 3.1%; P = .009) were more common after reoperative SAVR. Survival at 1, 5, 10, and 20 years was 94%, 82%, 64%, and 33% after reoperative SAVR and 95%, 86%, 72%, and 46% after elective primary isolated SAVR.

Conclusions

Risk of mortality and morbidity after reoperative SAVR has declined and is now similar to that of primary isolated SAVR. Decisions regarding prosthesis choice and SAVR versus transcatheter aortic valve replacement should be made in the context of lifelong disease management rather than avoidance of reoperation.

Section snippets

Patients

From January 1980 to July 2017, 7037 patients underwent reoperative (n = 753) or primary isolated (n = 6284) AVR at Cleveland Clinic (Figure E1). Patients who underwent emergency surgery, AVR for endocarditis, reoperative AVR during the same hospitalization as the index AVR, TAVR, allograft root replacement, or AVR with concomitant procedures were excluded (Appendix E1).

Mean age was 62 ± 14 years in patients who underwent reoperative AVR and 66 ± 13 years in those who underwent primary isolated

Reoperative Versus Primary Isolated AVR

The number of reoperative and primary isolated AVRs increased over the years (Figure 1). Patients were more likely to undergo reoperative AVR if they were younger (Figure E3, A), had a history of endocarditis, had clinical comorbidities, including chronic obstructive pulmonary disease and heart failure, but better left ventricular function (Figure E3, B) and more recent date of operation (Figure E3, C, and Table E1).

Hospital Mortality

Hospital mortality in all patients who had reoperative AVR was 2.8% (21 of

Principal Findings

Risk-adjusted hospital mortality after reoperative AVR in general and in the propensity score-matched cohorts is now similar to that for primary isolated AVR. This neutralization of risk extended to all major complications of cardiac surgery except bleeding, blood transfusions, and heart block. Late survival among matched patients diverged slightly after approximately 10 years, with somewhat better survival after primary isolated AVR (Figure 5).

Reoperative AVR

Sabik and colleagues22 noted a gradual reduction

Conclusion

Reoperation is not in itself a risk factor for hospital mortality after reoperative AVR. As a result, treatment decisions such as prosthesis choice for primary operation and optimal interventional approach (surgical AVR or valve-in-valve TAVR) for reoperation should be tailored to patient needs and expectations. These data support safe, planned reoperation as a strategy for younger patients who desire to avoid anticoagulation, and provide a basis for evaluating the success of valve-in-valve

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    This study was funded in part by the Seale Family Fund, the Burdett, Margaret and Eugene Larson Endowed Fund in Cardiovascular Innovation, the Marty and Michelle Weinberg and Family Fund, the Haslam Family Endowed Chair in Cardiovascular Medicine, the Stephens Family Endowed Chair in Cardiothoracic Surgery, and the Friends of the Cleveland Clinic Foundation.

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