Original article
Adult cardiac
Contemporary Outcomes of Repeat Aortic Valve Replacement: A Benchmark for Transcatheter Valve-in-Valve Procedures

Presented at the Fifty-first Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 24–28, 2015.
https://doi.org/10.1016/j.athoracsur.2015.04.062Get rights and content

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.

Section snippets

Study Population

The study population consisted of all patients who underwent re-AVR after previous AVR at hospitals participating in the STS ACSD from July 2011 to September 2013. All urgent/emergency cases were included in the study because in rare situation these patients may be treated with TAVR. Patients with endocarditis were included because the healed endocarditis group may be treated with TAVR. The study excluded patients aged younger than 20 years, those undergoing a concomitant cardiac procedure to

Results

From July 2011 to September 2013, 3,383 patients underwent isolated re-AVR after a previous AVR at 723 STS ACSD–participating sites. Three patients were excluded because they were aged younger than 20 years. Among the remaining 3,380 patients, 833 (25%) had undergone previous coronary artery bypass grafting with AVR, and 2,544 (75%) had previous isolated AVR. During the same period and institutions, 54,183 patients underwent a primary AVR.

Comment

The present study of 3,380 reoperative AVRs after a previous AVR is the largest series to date and provides widely generalizable information on the current practices and outcomes of this operation. This outcome has significant importance, because the emergence of V-in-V TAVR requires us to stratify the risk of re-AVR.

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Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.