The Risks and Benefits of Reoperation Aortic Valve Replacement

The Risks and Benefits of The Risks and Benefits of Reoperation Aortic Valve ReplacementReoperation Aortic Valve Replacement

Vincent Gaudiani, MD

Gary Grunkemeier, PhD

Luis Castro, MD

Audrey Fisher, MPH

YingXing Wu, MD

The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement

ObjectivesObjectives

Compare the surgical risks of first time Compare the surgical risks of first time AVR vs. re-operative AVR in 1213 AVR vs. re-operative AVR in 1213 consecutive unselected patients.consecutive unselected patients.

Determine the risk factors that predict Determine the risk factors that predict mortality in this series.mortality in this series.

Assess the clinical risk of reoperation AVR Assess the clinical risk of reoperation AVR compared to long term anticoagulation.compared to long term anticoagulation.


Risk of Anticoagulation Risk of Anticoagulation Related HemorrhageRelated Hemorrhage

The composite linearized rate of The composite linearized rate of anticoagulation related hemorrhage in anticoagulation related hemorrhage in several large series averages 0.9 – 2.5% several large series averages 0.9 – 2.5% per year.per year.

Akins, Ann Thor SurgAkins, Ann Thor Surg

61:806, 199661:806, 1996


Patient DemographicsPatient Demographics

First Op(n=887)

Reop(n=326) p-value

Age 71 69 .004

Female 43% 31% <.001

Renal Failure 7% 13% .005

Stroke 8% 11% NS

Diabetes 19% 23% NS

PVD 17% 26% .001

COPD 18% 19% NS


0%

5%

10%

15%

20%

25%

30%

35%

40%

% P

ts in

Ag

e G

rou

p

0-49 50-59 60-69 70-79 80+

Age Group

First Op(n=887)

Reop(n=326)

Age Histogram: Age Histogram: First Operation vs. ReoperationFirst Operation vs. Reoperation

* Statistically significant at p<.05

First Op Age Avg = 71

Reop Avg Age = 69*


Bio89%

Mech10%

Other1%

First Operation (n=887) Reoperation (n=326)

Bio73%

Mech23%

Other4%

Prostheses TypesProstheses Types


Prior Cardiac Operations Prior Cardiac Operations in Reoperative AVR’s (n=326)in Reoperative AVR’s (n=326)

4th Op5%

2nd Op75%

3rd OP19%

5th Op+1%


Cardiac FindingsCardiac Findings

First Op(n=887)

Reop(n=326) p-value

Ejection Fraction 52% 46% <.001

NYHA 3+ 67% 82% <.001

Congestive Heart Failure 75% 82% .010

Angina 30% 48% <.001

MI 5% 6% NS

Hypertension 63% 58% NS

Endocarditis

Active 1% 4% .037

Treated 2% 7% .001


Coronary DiseaseCoronary Disease

First Op(n=887)

Reop(n=326) p-value

# Diseased Vessels

None 56% 44% <.001

Single 14% 8% .001

Double 12% 8% .043

Triple 18% 40% <.001


Concomitant ProceduresConcomitant Procedures

First Op(n=887)

Reop(n=326) p-value

Coronary Artery Bypass 36% 39% NS

Mitral Valve Repair 3% 3% NS

Mitral Valve Replacement 9% 20% <.001

Tricuspid Valve Procedure 1% 6% <.001


Operative StatusOperative Status

First Op(n=887)

Reop(n=326) p-value

Status

Elective 70% 56% <.001

Urgent 28% 42% <.001

Emergent 2% 2% NS


Operative TimesOperative Times

First Op(n=887)

Reop(n=326) p-value

Perfusion Time (min) 85 99 <.001

Clamp Time (min) 67 78 <.001


Operative ResultsOperative Results

First Op(n=887)

Reop(n=326) p-value

Operative Death 4.1% 3.1% NS

Cerebrovascular Accident 4.7% 4.0% NS

Vent > 24h 11.9% 16.3% NS

Reexploration for bleed 4.6% 5.2% NS

Complete Heart Block 7.7% 9.8% NS

Renal Failure 3.4% 6.7% .027

Postop LOS 8.4 9.7 <.001


Factors Predicting Mortality by Factors Predicting Mortality by Multivariate Logistic Regression Multivariate Logistic Regression (p<0.10)(p<0.10)

Factor p-value Odds Ratio

•Preop Dialysis 0.004 6.61

•Preop Cardiogenic Shock 0.001 4.94

•NYHA Class IV 0.070 1.93

•Female 0.071 1.85

•Perfusion Time 0.005 1.11

•Age 0.023 1.04


Mortality by Age GroupMortality by Age Group

0%

1%

2%

3%

4%

5%

6%

7%%

Mo

rta

lity

0-59(n=221)

60-69(n=232)

70-79(n=443)

80+(n=317)

Age Group

All AVR(n=1213)


Mortality by Age GroupMortality by Age Group

4/148

1/73

4/162

2/7011/332

4/111

17/245

3/72

0%

1%

2%

3%

4%

5%

6%

7%

8%%

Mo

rta

lity

0-59 60-69 70-79 80+

Age Group

First Op (n=887)

Reop (n=326)


ConclusionsConclusions

The risks of re-operative AVR are lowThe risks of re-operative AVR are low

The risks of long-term anticoagulation are The risks of long-term anticoagulation are knownknown

We encourage all adult patients to choose We encourage all adult patients to choose the risks and benefits of tissue vs. the risks and benefits of tissue vs. mechanical AVR based upon a thorough mechanical AVR based upon a thorough discussion of these risksdiscussion of these risks


Prosthesis SelectionProsthesis Selection

“ The choice of one type of valve versus the other is largely based on the surgeons’ or cardiologists’ views on what is the least harmful for the patient-anticoagulation for life, or the risk of reoperation.”

Tirone E. David, M.D.Toronto General Hospital


Patient DemographicsPatient Demographics

First OpFirst Op RedoIsolated 1st Op

Isolated Redo

Redo Prev AVR

Redo Prev Other

N 887 326 376 55 134 192

Age 71.1 68.7 69.2 58.8 64.1 71.8

Female 43.1% 30.7% 41.3% 21.8% 29.9% 31.3%

Renal Failure 7.3% 13.2% 4.8% 12.7% 13.4% 13.0%

Stroke 7.7% 10.7% 6.1% 16.4% 10.4% 10.9%

Diabetes 19.3% 22.7% 14.1% 12.7% 13.4% 29.2%

PVD 16.9% 26.4% 9.3% 12.7% 14.9% 34.4%

COPD 18.0% 18.7% 16.8% 21.8% 19.4% 18.2%


Cardiac FindingsCardiac Findings

First Op Redo

Isolated 1st Op

Isolated Redo

Redo Prev AVR

Redo Prev Other

N 887 326 376 55 134 192

EF 51.6% 46.4% 53.0% 51.8% 50.0% 44.0%

NYHA

III 38.9% 42.6% 38.8% 34.5% 43.3% 42.2%

IV 27.7% 40.2% 18.6% 30.9% 34.3% 44.3%

CHF 75.2% 81.9% 72.6% 85.5% 82.1% 81.8%

Angina 29.9% 48.0% 3.4% 16.7% 45.5% 50.0%

MI 4.7% 6.1% 1.1% 0.0% 2.2% 8.9%

Hypertension 63.1% 58.3% 56.6% 49.1% 46.3% 66.7%

Endocarditis

Active 1.4% 3.7% 1.9% 9.1% 7.5% 1.0%

Treated 2.0% 7.4% 2.1% 20.0% 16.4% 1.0%


Coronary DiseaseCoronary Disease

First Op Redo

Isolated 1st Op

Isolated Redo

Redo Prev AVR

Redo Prev Other

N 887 326 376 55 134 192

# Diseased Vessels

None 55.8% 44.2% - - 63.4% 30.7%

Single 14.2% 7.7% - - 14.9% 2.6%

Double 11.7% 8.0% - - 8.2% 7.8%

Triple 18.3% 40.2% - - 13.4% 58.9%


Prior Cardiac OperationsPrior Cardiac Operations

First Op Redo

Isolated 1st Op

Isolated Redo

Redo Prev AVR

Redo Prev Other

N 887 326 376 55 134 192

# Prior Cardiac Operations

1 - 75.2% - 74.5% 73.9% 76.0%

2 - 18.7% - 14.5% 20.1% 17.7%

3 - 5.2% - 9.1% 5.2% 5.2%

4 - 0.9% - 1.8% 0.7% 1.0%


Concomitant ProceduresConcomitant Procedures

First Op(887)

Redo(326)

Isolated 1st Op(376)

Isolated Redo(55)

Redo Prev AVR(134)

Redo Prev Other(192)

N 887 326 376 55 134 192

CAB 36.2% 38.7% - - 25.4% 47.9%

MVV 3.0% 3.1% - - 3.0% 3.1%

MVR 9.4% 19.6% - - 23.1% 17.2%

TV 1.1% 6.4% - - 8.2% 5.2%


Operative StatusOperative Status

First Op Redo

Isolated 1st Op

Isolated Redo

Redo Prev AVR

Redo Prev Other

N 887 326 376 55 134 192

Status

Elective 69.9% 55.5% 78.5% 61.8% 57.5% 54.2%

Urgent 28.3% 42.3% 20.5% 34.5% 39.6% 44.3%

Emergent 1.6% 2.1% 1.1% 3.6% 3.0% 1.6%


Operative TimesOperative Times

First Op Redo

Isolated 1st Op

Isolated Redo

Redo Prev AVR

Redo Prev Other

N 887 326 376 55 134 192

Perfusion Time (min) 85 99 69 77 102 97

Clamp Time (min) 67 78 53 63 82 76


Operative ResultsOperative Results

First Op Redo

Isolated 1st Op

Isolated Redo

Redo Prev AVR

Redo Prev Other

N 887 326 376 55 134 192

Operative Death 4.1% 3.1% 3.2% 1.8% 3.0% 3.2%

CVA 4.7% 4.0% 3.5% 1.8% 2.2% 5.2%

Vent > 24h 11.9% 16.3% 5.1% 12.7% 13.4% 18.2%

Reexplore for bleed 4.6% 5.2% 2.9% 5.5% 6.0% 4.7%

Complete Heart Block 7.7% 9.8% 5.1% 7.3% 9.7% 9.9%

Renal Failure 3.4% 6.7% 2.4% 5.5% 4.5% 8.3%

Postop LOS 8.4 9.7 7.0 7.1 8.6 10.4

Documents

The Risks and Benefits of Reoperation Aortic Valve Replacement