With an increasingly elderly population and improvements in surgical and medical management, patients are living longer after cardiac surgery. Consequently, a higher percentage of patients with aortic valve disease are likely to undergo reoperative aortic valve replacement (AVR) in the foreseeable future. Previously, reoperative AVR was considered a high-risk operation with quoted mortality figures up to 15%. However, recent advances in management have improved outcomes therefore in this study the authors compared operative outcomes of reoperative AVR with primary AVR by surgical era.
In a retrospective case-control study using registry data from a single site during the period between 1996 and 2007, 1603 patients were studied. Of these 191 patients (12%) had had previous sternotomy for either coronary artery bypass grafting, aortic valve replacement, both, or another cardiac procedure. Patients were then divided into eras A (1996–1999), B (2000–2003), and C (2004–2007). Compared with early operative eras, patients in the most recent era were older and had higher preoperative EuroSCOREs, higher rates of preoperative dyslipidemia, coronary artery disease, and hypertension. Despite this, significantly more reoperative AVRs were performed in the most recent era. Mortality in the reoperative group decreased significantly with time (A 15.4%vs B 15.1%vs C 2.0%, P = 0.004) and was equivalent to the primary group in era C (3.5% vs. 2.0%, P = 0.65). Added to this, major complications also significantly decreased with time (A 25.6% vs. B 17.0% vs. C 6.1%, P = 0.006). There were no differences in outcome by initial cardiac operation in the reoperative group.
From their data, the authors conclude that reoperative aortic valve replacement in the current era now carries similar morbidity and mortality to primary replacement. While the advent of TAVI has been seen as a major threat to surgical aortic valve treatment, and has been considered as a potentially ideal treatment to avoid having to perform a second sternotomy, the procedure is still very much in its infancy and long term safety and durability data are still being gathered. These data suggest that reoperative AVR is now a less intimidating treatment option than before.
Reoperative AVR should now be considered a safe operation for patients requiring aortic valve replacement after a previous sternotomy.
LaPar DJ, Yang Z, Stukenborg GJ, Peeler BB, Kern JA, Kron IL, Ailawadi G. Outcomes of reoperative aortic valve replacement after previous sternotomy. J Thorac Cardiovasc Surg. 2010 Feb;139(2):263-72.