Re-do aortic valve replacement after previous homograft aortic … · 2019. 5. 24. · treatment of infective endocarditis: Executive summary J Thorac Cardiovasc Surg 153:1241-1258

Imperial College of Science Technology and Medicine

Aortic Unit Royal Brompton & Harefield NHS Foundation Trust

Aortic Unit, Royal Brompton & Harefield NHS Foundation Trust, UK

Re-do aortic valve replacement after previous homograft aortic root

replacement

Jullien Gaer, Toufan Bahrami, Fabio de Robertis, Ahmed Abdulsalam, John Pepper



Professor Sir Magdi Yacoub OM, FRS



Background

Cardiac surgical opinion remains divided over the use of aortic homografts

Pros Cons

Tissue handling Availability

Haemostasis Implantation

Resistance to infection Complexity of redo operation

Most reports of non-inferiority of mechanical valves/stented bioprostheses are underpowered with relatively high early mortality



Pettersson et al (2017) 2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: Surgical treatment of infective endocarditis: Executive summary J Thorac Cardiovasc Surg 153:1241-1258

Native valve IE CoR LoE

For invasive and destructive native aortic valve IE requiring root reconstruction and replacement, using an allograft may be beneficial, but a prosthetic bioroot or prosthetic valved conduit with a mechanical or bioprosthetic valve are acceptable alternatives, with choice guided by

surgeon training and experience

IIa B

Prosthetic valve IE

If there is annulus destruction and invasion outside the aortic root and root reconstruction and replacement is required, an allograft or a biologic tissue

root is preferable to a prosthetic valved conduit IIa B



McGiffin et al (1992) Aortic valve infection. Risk factors for death and recurrent endocarditis after aortic valve replacement. J Thorac Cardiovasc Surg 104:511-520



Hussain et al (2017) Challenging allograft use for aortic valve infective endocarditis: Is it the allograft or the surgeon?

J Thorac Cardiovasc Surg 153:280-1

Hussain et al (2017) Allografts remain a cornerstone of surgical treatment of invasive and destructive aortic valve infective endocarditis: Surgeon and technique do matter!

J Thorac Cardiovasc Surg 154:1900-1



Calcified homograft 10 years post-op



Calcified homograft 12 years post-op



Re-do aortic valve replacement after previous

homograft aortic root replacement

Retrospective study of the outcome of re-do aortic valve surgery in patients who had previously undergone homograft aortic root replacement The data were obtained from the Trust’s returns to NICOR (National Institute for Cardiovascular Research Outcomes) Long-term survival data cross-checked with the NHS Spine

Data are presented as mean ± standard error of the mean (μ±SEM)



Demographics

Between 1998 & 2016 , 318 patients were eligible for inclusion in the analysis

Age 56±4.5 years

Sex ratio M:F = 231:87 (2.7:1 )

Freedom from re-intervention: 11.8 ± 0.94 yrs



Operative urgency

Status Patients (n) %

Elective 242 76

Urgent 60 19

Emergency 16 5

20 patients (6%) were recorded as having active infective endocarditis at the time of surgery



Previous sternotomies

No. of previous sternotomies

Patients (n) %

1 218 69

2 77 24

3 21 7

4 2



Choice of aortic valve replacement

Procedure Patients (n) %

Mechanical AVR 108 34

Stented bioprosthesis 94 30

Homograft 64 20

Stentless bioprosthetic root 38 12

Pulmonary autograft 11 4

Rapid deployment bioprosthesis 2

Mechanical Bentall 1



Cardiopulmonary bypass

μ SEM

Cross-clamp time (min) 114 2.7

Total CPB time (min) 168 4.9

3 patients required mechanical circulatory support with either Levitronix or ECMO

Concomitant procedures

79 patients underwent one or more concomitant procedures including CABG, MVR/MV rep, other aortic procedures



Survival

30-day all cause/hospital mortality was 5.7% (18 patients)

Median duration of follow-up was 9.2 years



Kaplan-Meier survival curve

Pro

bab

ility

Year 2 4 6 8 10 12 14 16 18

No at risk 267 250 218 208 144 118 73 50 19

Time (years)



Actuarial survival

Years %

1 88

5 81

10 70

15 65



Duncan et al (2015) Valve-in-valve transcatheter aortic valve implantation for failing surgical aortic stentless bioprosthetic valves: A single-center experience J Thorac Cardiovasc Surg 150:90-98

22 patients (17 homografts, 3 SPV, 1 Freestyle, 1 David)

TAVR with CoreValve

Device migration in 3 cases

No early deaths

14% mortality at one year



Conclusions

Redo AVR after homograft aortic root replacement can be a daunting operation but can be accomplished with good short- and long-term outcomes

A versatile operative strategy is required in order to deal with the calcified aortic root

Concern about the complexity of the subsequent redo operation should not preclude homograft use when otherwise indicated, particularly in endocarditis

TAVR has an increasing role in all redo AVR surgery



CB 52y m

• Congenital bicuspid valve

• Valvotomy in childhood

• Lost to follow-up and re-presented in 2016 with severe AS

• S. aureus grown in blood but patient well, with normal serum markers, afebrile with normal WCC



CB 52y m • 25 mm CE stented

bioprosthesis

• Uneventful surgery

• TOE in theatre showed no PVL

• Uneventful 1st 12 hours

• Overnight became profoundly vasoplegic and febrile



CB 52y m • Emergency aortic root

replacement on Day 1 post-op

• Uneventful course thereafter

• On IV antibiotics for 6 weeks

Documents

Re-do aortic valve replacement after previous homograft aortic … · 2019. 5. 24. · treatment of infective endocarditis: Executive summary J Thorac Cardiovasc Surg 153:1241-1258