the risks and benefits of reoperation aortic valve replacement
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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.
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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*
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
Bio89%
Mech10%
Other1%
First Operation (n=887) Reoperation (n=326)
Bio73%
Mech23%
Other4%
Prostheses TypesProstheses Types
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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%
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
Operative TimesOperative Times
First Op(n=887)
Reop(n=326) p-value
Perfusion Time (min) 85 99 <.001
Clamp Time (min) 67 78 <.001
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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)
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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)
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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%
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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%
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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%
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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%
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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%
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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%
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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
The Risks and Benefits of Reoperation Aortic Valve The Risks and Benefits of Reoperation Aortic Valve ReplacementReplacement
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
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