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The Risks and Benefits of Reoperation Aortic Valve Replacement Vincent Gaudiani, MD Gary Grunkemeier, PhD Luis Castro, MD Audrey Fisher, MPH YingXing Wu,

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Presentation on theme: "The Risks and Benefits of Reoperation Aortic Valve Replacement Vincent Gaudiani, MD Gary Grunkemeier, PhD Luis Castro, MD Audrey Fisher, MPH YingXing Wu,"— Presentation transcript:

1 The Risks and Benefits of Reoperation Aortic Valve Replacement Vincent Gaudiani, MD Gary Grunkemeier, PhD Luis Castro, MD Audrey Fisher, MPH YingXing Wu, MD

2 The Risks and Benefits of Reoperation Aortic Valve Replacement 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.

3 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

4 The Risks and Benefits of Reoperation Aortic Valve Replacement Patient Demographics First Op (n=887) Reop (n=326)p-value Age Female 43%31%<.001 Renal Failure7%13%.005 Stroke8%11%NS Diabetes 19%23%NS PVD 17%26%.001 COPD18%19%NS

5 The Risks and Benefits of Reoperation Aortic Valve Replacement Age Histogram: First Operation vs. Reoperation * Statistically significant at p<.05 First Op Age Avg = 71 Reop Avg Age = 69 *

6 The Risks and Benefits of Reoperation Aortic Valve Replacement First Operation (n=887) Reoperation (n=326) Prostheses Types

7 The Risks and Benefits of Reoperation Aortic Valve Replacement Prior Cardiac Operations in Reoperative AVRs (n=326)

8 The Risks and Benefits of Reoperation Aortic Valve Replacement Cardiac Findings First Op (n=887) Reop (n=326)p-value Ejection Fraction52%46%<.001 NYHA 3+ 67% 82%<.001 Congestive Heart Failure75%82%.010 Angina30%48%<.001 MI 5%6%NS Hypertension63%58%NS Endocarditis Active1%4%.037 Treated2%7%.001

9 The Risks and Benefits of Reoperation Aortic Valve Replacement Coronary Disease First Op (n=887) Reop (n=326)p-value # Diseased Vessels None56%44%<.001 Single14%8%.001 Double12%8%.043 Triple18%40%<.001

10 The Risks and Benefits of Reoperation Aortic Valve Replacement Concomitant Procedures First Op (n=887) Reop (n=326)p-value Coronary Artery Bypass 36%39%NS Mitral Valve Repair3% NS Mitral Valve Replacement9%20%<.001 Tricuspid Valve Procedure 1%6%<.001

11 The Risks and Benefits of Reoperation Aortic Valve Replacement Operative Status First Op (n=887) Reop (n=326)p-value Status Elective 70%56%<.001 Urgent 28%42%<.001 Emergent 2% NS

12 The Risks and Benefits of Reoperation Aortic Valve Replacement Operative Times First Op (n=887) Reop (n=326)p-value Perfusion Time (min) 8599<.001 Clamp Time (min) 6778<.001

13 The Risks and Benefits of Reoperation Aortic Valve Replacement Operative 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 Block7.7%9.8%NS Renal Failure3.4%6.7%.027 Postop LOS <.001

14 The Risks and Benefits of Reoperation Aortic Valve Replacement Factors Predicting Mortality by Multivariate Logistic Regression (p<0.10) Factor p-value Odds Ratio Preop Dialysis Preop Cardiogenic Shock NYHA Class IV Female Perfusion Time Age

15 The Risks and Benefits of Reoperation Aortic Valve Replacement Mortality by Age Group

16 The Risks and Benefits of Reoperation Aortic Valve Replacement Mortality by Age Group

17 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

18 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

19 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 Age 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%

20 The Risks and Benefits of Reoperation Aortic Valve Replacement Cardiac Findings First OpRedo Isolated 1st Op Isolated Redo Redo Prev AVR Redo Prev Other N EF 51.6%46.4%53.0%51.8%50.0%44.0% NYHA III38.9%42.6%38.8%34.5%43.3%42.2% IV27.7%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 Active1.4%3.7%1.9%9.1%7.5%1.0% Treated2.0%7.4%2.1%20.0%16.4%1.0%

21 The Risks and Benefits of Reoperation Aortic Valve Replacement Coronary Disease First OpRedo Isolated 1st Op Isolated Redo Redo Prev AVR Redo Prev Other N # Diseased Vessels None55.8%44.2%--63.4%30.7% Single14.2%7.7%--14.9%2.6% Double11.7%8.0%--8.2%7.8% Triple18.3%40.2%--13.4%58.9%

22 The Risks and Benefits of Reoperation Aortic Valve Replacement Prior Cardiac Operations First OpRedo Isolated 1st Op Isolated Redo Redo Prev AVR Redo Prev Other N # Prior Cardiac Operations %-74.5%73.9%76.0% %-14.5%20.1%17.7% 3-5.2%-9.1%5.2% 4-0.9%-1.8%0.7%1.0%

23 The Risks and Benefits of Reoperation Aortic Valve Replacement Concomitant Procedures First Op (887) Redo (326) Isolated 1st Op (376) Isolated Redo (55) Redo Prev AVR (134) Redo Prev Other (192) N 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%

24 The Risks and Benefits of Reoperation Aortic Valve Replacement Operative Status First OpRedo Isolated 1st Op Isolated Redo Redo Prev AVR Redo Prev Other N 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%

25 The Risks and Benefits of Reoperation Aortic Valve Replacement Operative Times First OpRedo Isolated 1st Op Isolated Redo Redo Prev AVR Redo Prev Other N Perfusion Time (min) Clamp Time (min)

26 The Risks and Benefits of Reoperation Aortic Valve Replacement Operative Results First OpRedo Isolat ed 1st Op Isolate d Redo Redo Prev AVR Redo Prev Other N 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 Block7.7%9.8%5.1%7.3%9.7%9.9% Renal Failure3.4%6.7%2.4%5.5%4.5%8.3% Postop LOS


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