The Risks and Benefits of Reoperation 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 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. 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

The Risks and Benefits of Reoperation Aortic Valve Replacement Patient 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% PVD  17% 26% .001 COPD 18% 19% The Risks and Benefits of Reoperation Aortic Valve Replacement

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

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

Prior Cardiac Operations in Reoperative AVR’s (n=326) The Risks and Benefits of Reoperation Aortic Valve Replacement

The Risks and Benefits of Reoperation Aortic Valve Replacement Cardiac Findings   First Op (n=887) Reop (n=326) p-value Ejection Fraction 52% 46% <.001 NYHA 3+  67%  82% Congestive Heart Failure 75% 82% .010 Angina 30% 48% MI  5% 6% NS Hypertension 63% 58% Endocarditis Active 1% 4% .037 Treated 2% 7% .001 The Risks and Benefits of Reoperation Aortic Valve Replacement

The Risks and Benefits of Reoperation Aortic Valve Replacement Coronary Disease   First Op (n=887) Reop (n=326) p-value # Diseased Vessels  None 56% 44% <.001 Single 14% 8% .001 Double 12% .043 Triple 18% 40% 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 Repair 3% Mitral Valve Replacement 9% 20% <.001 Tricuspid Valve Procedure  1% 6% The Risks and Benefits of Reoperation Aortic Valve Replacement

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% Emergent 2% NS The Risks and Benefits of Reoperation Aortic Valve Replacement

The Risks and Benefits of Reoperation Aortic Valve Replacement Operative Times   First Op (n=887) Reop (n=326) p-value Perfusion Time (min)  85 99 <.001 Clamp Time (min) 67 78 The Risks and Benefits of Reoperation Aortic Valve Replacement

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% Vent > 24h  11.9% 16.3% Reexploration for bleed  4.6% 5.2% Complete Heart Block 7.7% 9.8% Renal Failure 3.4% 6.7% .027 Postop LOS  8.4 9.7 <.001 The Risks and Benefits of Reoperation Aortic Valve Replacement

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 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

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

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

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

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

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 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% 29.2% PVD 16.9% 26.4% 9.3% 14.9% 34.4% COPD 18.0% 18.7% 16.8% 19.4% 18.2% The Risks and Benefits of Reoperation Aortic Valve Replacement

The Risks and Benefits of Reoperation Aortic Valve Replacement Cardiac 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% 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% The Risks and Benefits of Reoperation Aortic Valve Replacement

The Risks and Benefits of Reoperation Aortic Valve Replacement Coronary 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 Replacement

Prior 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% 4 0.9% 1.8% 0.7% 1.0% 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 887 326 376 55 134 192 CAB 36.2% 38.7% - 25.4% 47.9% MVV 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 Replacement

The Risks and Benefits of Reoperation Aortic Valve Replacement Operative 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% The Risks and Benefits of Reoperation Aortic Valve Replacement

The Risks and Benefits of Reoperation Aortic Valve Replacement Operative 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 Replacement

The Risks and Benefits of Reoperation Aortic Valve Replacement Operative 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% CVA  4.7% 4.0% 3.5% 2.2% 5.2% Vent > 24h  11.9% 16.3% 5.1% 12.7% 13.4% 18.2% Reexplore for bleed  4.6% 2.9% 5.5% 6.0% 4.7% Complete Heart Block 7.7% 9.8% 7.3% 9.7% 9.9% Renal Failure 3.4% 6.7% 2.4% 4.5% 8.3% Postop LOS  8.4 9.7 7.0 7.1 8.6 10.4 The Risks and Benefits of Reoperation Aortic Valve Replacement