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.
The Risks and Benefits of Reoperation Aortic Valve Replacement

3. 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

4. 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

5. * 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

6. 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

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

8. 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

9. 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

10. 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

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

12. 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

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%
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

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
The Risks and Benefits of Reoperation Aortic Valve Replacement

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

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

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
The Risks and Benefits of Reoperation Aortic Valve Replacement

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
The Risks and Benefits of Reoperation Aortic Valve Replacement

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
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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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