Transcript The Risks and Benefits of Reoperation Aortic Valve Replacement Vincent Gaudiani, MD Gary Grunkemeier, PhD Luis Castro, MD Audrey Fisher, MPH YingXing Wu, MD Objectives Compare the surgical.

The Risks and Benefits of
Reoperation Aortic Valve Replacement
Vincent Gaudiani, MD
Gary Grunkemeier, PhD
Luis Castro, MD
Audrey Fisher, MPH
YingXing Wu, MD
Objectives
Compare the surgical risks of first time
AVR vs. re-operative AVR in 1213
consecutive unselected patients.
Determine the risk factors that predict
mortality in this series.
Assess the clinical risk of reoperation AVR
compared to long term anticoagulation.
The Risks and Benefits of Reoperation Aortic Valve Replacement
Risk of Anticoagulation
Related Hemorrhage
The composite linearized rate of
anticoagulation related hemorrhage in
several large series averages 0.9 – 2.5%
per year.
Akins, Ann Thor Surg
61:806, 1996
The Risks and Benefits of Reoperation Aortic Valve Replacement
Patient Demographics
First Op
(n=887)
Reop
(n=326)
Age
Female
Renal Failure
71
43%
7%
69
31%
13%
Stroke
Diabetes
PVD
COPD
8%
19%
17%
18%
11%
23%
26%
19%
p-value
.004
<.001
.005
NS
NS
.001
NS
The Risks and Benefits of Reoperation Aortic Valve Replacement
Age Histogram:
First Operation vs. Reoperation
% Pts in Age Group
40%
35%
30%
*
First Op Age Avg = 71
Reop Avg Age = 69
25%
20%
First Op
(n=887)
15%
Reop
(n=326)
10%
5%
0%
0-49
50-59
60-69
70-79
80+
Age Group
* Statistically significant at p<.05
The Risks and Benefits of Reoperation Aortic Valve Replacement
Prostheses Types
First Operation (n=887)
Mech
10%
Other
1%
Reoperation (n=326)
Mech
23%
Other
4%
Bio
89%
The Risks and Benefits of Reoperation Aortic Valve Replacement
Bio
73%
Prior Cardiac Operations
in Reoperative AVR’s (n=326)
3rd OP
19%
4th Op
5%
5th Op+
1%
2nd Op
75%
The Risks and Benefits of Reoperation Aortic Valve Replacement
Cardiac Findings
First Op
Reop
(n=887) (n=326) p-value
Ejection Fraction
NYHA 3+
Congestive Heart Failure
52%
67%
75%
46%
82%
82%
<.001
<.001
.010
Angina
MI
Hypertension
Endocarditis
Active
Treated
30%
5%
63%
48%
6%
58%
<.001
NS
NS
1%
2%
4%
7%
.037
.001
The Risks and Benefits of Reoperation Aortic Valve Replacement
Coronary Disease
# Diseased Vessels
None
Single
Double
Triple
First Op
(n=887)
Reop
(n=326)
p-value
56%
14%
12%
18%
44%
8%
8%
40%
<.001
.001
.043
<.001
The Risks and Benefits of Reoperation Aortic Valve Replacement
Concomitant Procedures
First Op
(n=887)
Reop
(n=326)
p-value
36%
39%
NS
Mitral Valve Repair
3%
3%
NS
Mitral Valve Replacement
9%
20%
<.001
Tricuspid Valve Procedure
1%
6%
<.001
Coronary Artery Bypass
The Risks and Benefits of Reoperation Aortic Valve Replacement
Operative Status
First Op
(n=887)
Reop
(n=326)
p-value
70%
28%
2%
56%
42%
2%
<.001
<.001
NS
Status
Elective
Urgent
Emergent
The Risks and Benefits of Reoperation Aortic Valve Replacement
Operative Times
Perfusion Time (min)
Clamp Time (min)
First Op
(n=887)
85
67
Reop
(n=326) p-value
99
<.001
78
<.001
The Risks and Benefits of Reoperation Aortic Valve Replacement
Operative Results
Operative Death
Cerebrovascular Accident
Vent > 24h
Reexploration for bleed
Complete Heart Block
Renal Failure
Postop LOS
First Op
Reop
(n=887) (n=326) p-value
4.1%
3.1%
NS
4.7%
11.9%
4.6%
7.7%
3.4%
8.4
4.0%
16.3%
5.2%
9.8%
6.7%
9.7
The Risks and Benefits of Reoperation Aortic Valve Replacement
NS
NS
NS
NS
.027
<.001
Factors Predicting Mortality by
Multivariate Logistic Regression (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
The Risks and Benefits of Reoperation Aortic Valve Replacement
Mortality by Age Group
7%
% Mortality
6%
5%
4%
3%
All AVR
(n=1213)
2%
1%
0%
0-59
60-69
70-79
80+
(n=221) (n=232) (n=443) (n=317)
Age Group
The Risks and Benefits of Reoperation Aortic Valve Replacement
Mortality by Age Group
8%
17/245
7%
% Mortality
6%
5%
4/111
4%
3%
4/148
2/70
3/72
First Op (n=887)
Reop (n=326)
11/332
4/162
2%
1/73
1%
0%
0-59
60-69
70-79
80+
Age Group
The Risks and Benefits of Reoperation Aortic Valve Replacement
Conclusions
The risks of re-operative AVR are low
The risks of long-term anticoagulation are
known
We encourage all adult patients to choose
the risks and benefits of tissue vs.
mechanical AVR based upon a thorough
discussion of these risks
The Risks and Benefits of Reoperation Aortic Valve Replacement
Prosthesis 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
The Risks and Benefits of Reoperation Aortic Valve Replacement
Patient Demographics
First Op
Redo
Isolated
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
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%
Female
The Risks and Benefits of Reoperation Aortic Valve Replacement
Cardiac Findings
First
Op
N
Redo
Isolated
1st Op
Isolated
Redo
Redo
Prev
AVR
Redo
Prev
Other
887
326
376
55
134
192
51.6%
46.4%
53.0%
51.8%
50.0%
44.0%
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%
4.7%
6.1%
1.1%
0.0%
2.2%
8.9%
63.1%
58.3%
56.6%
49.1%
46.3%
66.7%
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%
EF
NYHA
MI
Hypertension
Endocarditis
The Risks and Benefits of Reoperation Aortic Valve Replacement
Coronary Disease
First
Op
N
Redo
Isolated
1st Op
Isolated
Redo
376
55
887
326
None
55.8%
44.2%
-
Single
14.2%
7.7%
Double
11.7%
Triple
18.3%
Redo
Prev
AVR
Redo
Prev
Other
134
192
-
63.4%
30.7%
-
-
14.9%
2.6%
8.0%
-
-
8.2%
7.8%
40.2%
-
-
13.4%
58.9%
# Diseased
Vessels
The Risks and Benefits of Reoperation Aortic Valve Replacement
Prior Cardiac Operations
First Op
N
887
Redo
Redo
Prev
AVR
Redo
Prev
Other
Isolated
1st Op
Isolated
Redo
376
55
134
192
326
# 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%
The Risks and Benefits of Reoperation Aortic Valve Replacement
Concomitant Procedures
First Op
(887)
N
Redo
(326)
Isolated
1st Op
(376)
887
326
CAB
36.2%
38.7%
-
MVV
3.0%
3.1%
MVR
9.4%
TV
1.1%
Isolated
Redo
(55)
376
55
Redo
Prev
AVR
(134)
Redo
Prev
Other
(192)
134
192
-
25.4%
47.9%
-
-
3.0%
3.1%
19.6%
-
-
23.1%
17.2%
6.4%
-
-
8.2%
5.2%
The Risks and Benefits of Reoperation Aortic Valve Replacement
Operative Status
First
Op
N
Redo
Isolated
1st Op
Isolated
Redo
Redo
Prev
AVR
Redo
Prev
Other
887
326
376
55
134
192
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%
Status
The Risks and Benefits of Reoperation Aortic Valve Replacement
Operative Times
First
Op
N
Redo
Isolated
1st Op
Isolated
Redo
Redo
Prev
AVR
Redo
Prev
Other
887
326
376
55
134
192
Perfusion Time
(min)
85
99
69
77
102
97
Clamp Time
(min)
67
78
53
63
82
76
The Risks and Benefits of Reoperation Aortic Valve Replacement
Operative Results
Redo
Isolat
ed 1st
Op
Isolate
d Redo
Redo
Prev AVR
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%
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%
8.4
9.7
7.0
7.1
8.6
10.4
First Op
N
Vent > 24h
Postop LOS
The Risks and Benefits of Reoperation Aortic Valve Replacement
Redo
Prev
Other