The Journal of Thoracic and Cardiovascular Surgery
Adult: Aortic ValveThe decreasing risk of reoperative aortic valve replacement: Implications for valve choice and transcatheter therapy
Graphical abstract
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.