EARLY AND LATE OUTCOME AFTER REPAID AORTIC VALVE SURGERY - THE SINGEL CENTRE EXPERIANCE OF HEART CENTER LEIPZIG (GERMANY)

Introduction. The number of patients that need repeated operations on aortic valve due to dysfunction or degeneration of previously implanted prosthesis is constantly increasing throughout the world because of the constant growth of number of operated patients. The aim of our study was to assess the clinical outcomes of repeated surgeries for aortic valves, held at the Heart Centre of the University of Leipzig (Germany) from 1994 to 2008. Materials and methods. The study included 155 patients, 86 patients of which have had aortic valve prosthesis without reconstruction of the aortic root (rAVS) and 69 patients aortic root replacement (rAVR). The average time between operations amounted to 6.7 ± 7.9 years for all patients; 2.9 ± 3.1 and 8.8 ± 6.7 years for patients with implanted mechanical and biological valves, respectively. Results. The findings showed early lethality of 4.5% for all patients (3.5% for rAVS without root and 5.8% for rAVR with root, p = 0.5). Five-and eight-year survival is 66 ± 5% and 61 ± 6% for all patients and does not differ between surgical groups. Left ventricular ejection fraction is less than 30% (OR 9.2, 95% CI 1.1 -80.3) and initial neurological deficit (OR 22.1, 95% CI 2.3 -197.4) were independent predictors of early mortality. Independent predictors of late mortality were: NYHA functional class IV (HR, 95% CI 2.2 = 1.5, p -3.2 < 0.01) and infective endocarditis (HR 2.2, 95% CI = 1.4 -3.1 p < 0.01). Conclusions. Thus, repeated surgeries on aortic valve is associated with the acceptable early and late survival.

1. Beckmann A, Funkat AK, Lewandowski J, Frie M, Ernst M, Hekmat K, et al. Cardiac surgery in Germany during 2014: a report on behalf of the german society for thoracic and cardiovascular surgery. Thorac Cardiovasc Surg. 2015; 63(4):258-69. DOI: 10.1055/s0035-1551676.

2. Oxenham H, Bloomfield P, Wheatley DJ, Lee RJ, Cunningham J, Prescott RJ, et al. Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart. 2003;89(7):715-21. PMCID: PMC1767737.

3. Lehmann S, Leontjev S, Kempfert J., Rastan A., Garbade J., Borger MA, et al. Mid-term results after Epic™ xenograft implantation for aortic, mitral, and double valve replacement. J Heart Valve Dis. 2007;16(6):641-8. PMID: 18095514.

4. Brown ML, Schaff HV, Lahr BD, Mullany CJ, Sundt TM, Dearani JA, et al. Aortic valve replacement in patients aged 50 to 70 years: improved outcome with mechanical versus biologic prostheses. J Thorac Cardiovasc Surg. 2008;135(4):878-84. DOI: 10.1016/j. jtcvs.2007.10.065.

5. Potter DD, Sundt TM 3rd, Zehr KJ, Dearani JA, Daly RC, Mullany CJ, et al. Operative risk of reoperative aortic valve replacement. J Thorac Cardiovasc Surg. 2005;129(1):94-103. DOI: 10.1016/j.jtcvs.2004.08.02.

6. David TE, Regesta T, Gavra G, Armstrong S, Maganti MD. Surgical treatment of paravalvular abscess: long-term results. Eur J Cardiothorac Surg. 2007;31(1):43-8. DOI: 10.1016/j.ejcts.2006.10.036.

7. Leontyev S, Davierwala PM, Krögh G, Feder S, Oberbach A, Bakhtiary F, et al. Early and late outcomes of complex aortic root surgery in patients with aortic root abscesses. Eur J Cardiothorac Surg. 2016;49(2):447-55. DOI: 10.1093/ejcts/ezv138.

8. Jamieson WR, Burr LH, Miyagishima RT, Janusz MT, Fradet GJ, Ling H, et al. Re-operation for bioprosthetic aortic structural failure - risk assessment. Eur J Cardiothorac Surg. 2003;24(6):873-8. PMID: 14643803.

9. Davierwala PM, Borger MA, David TE, Rao V, Maganti M, Yau TM. Reoperation is not an independent predictor of mortality during aortic valve surgery. J Thorac Cardiovasc Surg. 2006;131(2):329-35. DOI: 10.1016/j.jtcvs.2005.09.022.

10. Kumar P, Athanasiou T, Ali A, Nair S, Oz BS, DeSouza A, et al. Redo aortic valve replacement: does a previous homograft influence the operative outcome? J Heart Valve Dis. 2004;13(6):904-13. PMID: 15597580.

11. Kirsch EW, Radu NC, Mekontso-Dessap A, Hillion M-L, Loisanceet D. Aortic root replacement after previous surgical intervention on the aortic valve, aortic root, or ascending aorta. J Thorac Cardiovasc Surg. 2006;131(3):601-8. DOI:10.1016/j.jtcvs.2005.11.007.

12. Dvir D, Webb JG, Bleiziffer S, Pasic M, Waksman R, Kodali S, et al. Transcatheter aortic valve implantation in failed bioprosthetic surgical valves. JAMA. 2014;312(2):162-70. DOI: 10.1001/ jama.2014.7246.

13. Walther T, Kempfert J, Borger MA, Fassl J, Falk V, Blumenstein J, et al. Human minimally invasive off-pump valve-in-a-valve implantation. Ann Thorac Surg. 2008;85(3):1072-3. DOI: 10.1016/j. athoracsur.2007.12.040.

14. Bourguignon T, El Khoury R, Candolfi P, Loardi C, Mirza A, Boulanger-Lothion J, et al. Very long-term outcomes of the Carpentier-Edwards perimount aortic valve in patients aged 60 or younger. Ann Thorac Surg. 2015;100(3):853-9. DOI: 10.1016/j.athoracsur.2015.03.105.

15. Bourguignon T, Lhommet P, El Khoury R, Candolfi P, Loardi C, Mirza A, et al. Very long-term outcomes of the Carpentier-Edwards Perimount aortic valve in patients aged 50-65 years. Eur J Cardiothorac Surg. 2016;49(5):1462-8. DOI: 10.1093/ejcts/ezv384.

16. Vogt PR, Brunner-LaRocca H-P, Sidler P, Zuönd G, Truniger K, Lachat M, et al. Reoperative surgery for degenerated aortic bioprostheses: predictors for emergency surgery and reoperative mortality. Eur J Cardiothorac Surg. 2000;17(2):134-9. DOI: 10.1016/ S1010-7940(99)00363-2.

17. Borger MA, Prasongsukarn K, Armstrong S, Feindel CM, David TE. Stentless aortic valve reoperations: a surgical challenge. Ann Thorac Surg. 2007;84(3):73744. DOI: 10.1016/j.athoracsur.2007.04.061.

18. Tang GH, Maganti M, David TE, Feindel CM, Scully HE, Borger MA. Effect of prior valve type on mortality in reoperative valve surgery. Ann Thorac Surg. 2007;83(3):938-45. DOI: 10.1016/j. athoracsur.2006.07.047.

19. Leontyev S, Borger MA, Modi P, Lehmann S, Seeburger J, Doenst T, et al. Surgical management of aortic root abscess: a 13-year experience in 172 patients with 100% follow-up. J Thorac Cardiovasc Surg. 2012;143(2):332-7. DOI: 10.1016/j.jtcvs.2010.10.064.

20. Leontyev S, Borger MA, Modi P, Lehmann S, Seeburger J, Walther T, et al. Redo aortic valve surgery: influence of prosthetic valve endocarditis on outcomes. J Thorac Cardiovasc Surg. 2011;142(1):99-105. DOI: 10.1016/j.jtcvs.2010.08.042.

21. Sadowski J, Kapelak B, Bartus K, Podolec P, Rudzinski P, Myrdko T, et al. Reoperation after fresh homograft replacement: 23 years’ experience with 655 patients. Eur J Cardiothorac Surg. 2003;23(6):9961001. PMID: 12829078.

22. Szeto WY, Bavaria JE, Bowen FW, Geirsson A, Cornelius K, Hargrove WC, et al. Reoperative aortic root replacement in patients with previous aortic surgery. Ann Thorac Surg. 2007;84(5):1592-9. DOI: 10.1016/j. athoracsur.2007.05.049.

23. David TE, Feindel CM, Ivanov J, Armstrong S. Aortic root replacement in patients with previous heart surgery. J Card Surg. 2004;19(4):325-8. DOI: 10.1111/j.0886-0440.2004.4058_11.x.

24. Dougenis D, Daily BB, Kouchoukos NT. Reoperations on the aortic root and ascending aorta. Ann Thorac Surg. 1997;64(4):986-92. DOI: 10.1016/ S0003-4975(97)00626-7.

25. Habib G, Tribouilloy C, Thuny F, Giorgi R, Brahim A, Amazouz M, et al. Prosthetic valve endocarditis: who needs surgery? A multicentre study of 104 cases. Heart. 2005;91(7):954-9. DOI: 10.1136/hrt.2004.046177.

26. Lopes S, Calvinho P, de Oliveira F, Antunes M. Allograft aortic root replacement in complex prosthetic endocarditis. Eur J Cardiothorac Surg. 2007;32(1):12632. DOI: 10.1016/j.ejcts.2007.01.076.

27. Toker ME, Kirali K, Balkanay M, Eren E, Ozen Y, Göler M, et al. Operative mortality after valvular reoperations. Heart Surg Forum. 2005;8(4):E280-3. DOI: 10.1532/HSF98.20041154.

28. Hammermeister K, Sethi GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol. 2000;36(4):1152-8. PMID: 11028464.

29. Dvir D, Webb JG. Transcatheter aortic valvein-valve implantation for patients with degenerative surgical bioprosthetic valves. Circ J. 2015;79(4):695703. DOI: 10.1253/circj.CJ-14-1418.