Aortic root allograft reoperations

James C Witten; Juan Umana-Pizano; Penny L Houghtaling; Joshua E Insler; Ozgun Erten; Edward R Nowicki; Lars G Svensson; Eugene H Blackstone; Shinya Unai; Gösta B Pettersson

doi:10.1016/j.jtcvs.2023.02.009

Aortic root allograft reoperations

J Thorac Cardiovasc Surg. 2023 Feb 15:S0022-5223(23)00164-2. doi: 10.1016/j.jtcvs.2023.02.009. Online ahead of print.

Affiliations

¹ Department of Thoracic and Cardiovascular Surgery, Heart, Thoracic, and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
² Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
³ Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio.
⁴ Department of Thoracic and Cardiovascular Surgery, Heart, Thoracic, and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
⁵ Department of Thoracic and Cardiovascular Surgery, Heart, Thoracic, and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: unais@ccf.org.

PMID: 37074251
DOI: 10.1016/j.jtcvs.2023.02.009

Abstract

Objective: To investigate outcomes after aortic root allograft reoperation, identify risk factors for morbidity and mortality, and describe practice evolution since publication of our 2006 allograft reoperation study.

Methods: From January 1987 to July 2020, 602 patients underwent 632 allograft-related reoperations at Cleveland Clinic: 144 before 2006 (early era, which suggested radical explant was superior to aortic-valve-replacement-within-allograft [AVR-only]), and 488 from 2006 to present (recent era). Indications for reoperation were structural valve deterioration in 502 (79%), infective endocarditis in 90 (14%), and nonstructural valve deterioration/noninfective endocarditis in 40 (6.3%). Reoperative techniques included radical allograft explant in 372 (59%), AVR-only in 248 (39%), and allograft preservation in 12 (1.9%). Perioperative events and survival were assessed among indications, techniques, and eras.

Results: Operative mortality by indication was 2.2% (n = 11) for structural valve deterioration, 7.8% (n = 7) in those with infective endocarditis, and 7.5% (n = 3) for nonstructural valve deterioration/noninfective endocarditis, and by surgical approach 2.4% (n = 9) after radical explant, 4.0% (n = 10) for AVR-only, and 17% (n = 2) for allograft preservation. Operative adverse events occurred in 4.9% (n = 18) of radical explants and 2.8% (n = 7) of AVR-only procedures (P = .2). Patients undergoing radical explants received larger valves than those undergoing AVR-only (median, 25 vs 23 mm).

Conclusions: Aortic root allograft reoperations present a technical challenge but can be performed with low mortality and morbidity. Radical explant offers outcomes similar to AVR-only while allowing for implant of larger prostheses. Increasing experience with allograft reoperations has permitted excellent outcomes; thus, risk of reoperation should not dissuade surgeons from using allografts for invasive aortic valve infective endocarditis and other indications.

Keywords: adult cardiac surgery; aortic valve replacement; infective endocarditis; structural valve deterioration.