In which patients is transcatheter aortic valve replacement potentially better indicated than surgery for redo aortic valve disease? Long-term results of a 10-year surgical experience

Abstract

Background: Redo aortic valve replacement procedures have been reduced by the growing practice of trans-catheter aortic valve-in-valve procedures. We analyzed our long-term results of redo aortic valve replacement procedures during a 10-year period in an effort to define subgroups in which trans-catheter aortic valve-in-valve procedures may be better than surgery.

Methods: From 2002 to 2010, 131 redo aortic valve replacement procedures with at least 18 months of follow-up were prospectively enrolled. Hospital and follow-up outcome of the entire population and of high-risk subgroups were evaluated.

Results: Hospital mortality was 2.3%, major re-entry complications were seen in 1.5%, re-exploration for bleeding was seen in 9.2%, perioperative low cardiac output state (ie, low cardiac output syndrome) was seen in 9.9%, stroke was seen in 3.1%, prolonged ventilation was seen in 18.3%, pneumonia was seen in 4.6%, acute renal insufficiency was seen in 11.5%, intra-aortic counterpulsation (intra-aortic balloon pump) was seen in 9.2%, renal replacement therapy was seen in 4.6%, need for transfusions was seen in 60.3%, and permanent pacemaker implantation was seen in 2.3%. One hundred twenty-month actuarial survival, freedom from acute heart failure, reinterventions, stroke, and thromboembolisms were 61.5% ± 8.6%, 62.9% ± 6.9%, 97.8% ± 1.5%, 93.2% ± 3.0%, and 91.2% ± 3.2%, respectively. Patients aged >75 years had similar outcome to younger patients (nonsignificant P for all). Endocarditis resulted in higher hospital mortality (P = .034), low cardiac output state (P < .0001), intra-aortic balloon pump (P < .0001), prolonged ventilation (P = .011), pneumonia (P = .049), acute renal insufficiency (P = .004), lower actuarial survival (log-rank P = .0001), freedom from acute heart failure (P = .002), and re-intervention (P = .003). New York Heart Association functional class IV at admission resulted in a higher incidence of low cardiac output state (P < .0001), intra-aortic balloon pump (P = .0001), prolonged ventilation (P < .0001), pneumonia (P = .015), and a lower actuarial freedom from re-intervention (P = .0001). Higher need for permanent pacemaker implantation (P = .015) and lower freedom from acute heart failure (P = .019) emerged after urgencies/emergencies.

Conclusions: Redo aortic valve replacement procedures achieves good results, especially in nonendocarditic or elective cases, and young or New York Heart Association functional class I/II patients. Indeed, endocarditis significantly affects outcome. New York Heart Association functional class IV and nonelective procedures might benefit from trans-catheter aortic valve-in-valve procedures.