Pr. Vogt et al., Reoperative surgery for degenerated aortic bioprostheses: predictors for emergency surgery and reoperative mortality, EUR J CAR-T, 17(2), 2000, pp. 134-139
Objective: The long-term outcome of patients with aortic bioprosthetic valv
es could be improved by decreasing the reoperative mortality rate. Methods:
Predictors of emergency reoperation and reoperative mortality were identif
ied retrospectively in 172 patients who had the first bioprosthetic aortic
valve replacement between 1975 and 1988 (mean age 46 +/- 13 years) and were
subjected to replacement of the degenerated bioprostheses between 1978 and
1997 (mean age 56 +/- 14 years). Emergency reoperation had to be performed
in 31 patients (18%). Results: The operative mortality was 5.2% (9/172), 2
2.6% for emergency (odds ratio 11.17; 95%-confidence limit 4.33-28.85) and
1.4% for elective replacement of the degenerated aortic bioprosthesis (P <
0.0001; OR = 20.3). Patients who died at reoperation had higher transvalvul
ar gradients before the primary aortic valve replacement (P = 0.007), recei
ved smaller bioprostheses at the first operation (P = 0.03), had later recu
rrence of symptoms after the first aortic valve replacement (P = 0.04), a h
igher pre-reoperative New York Heart Association (NYHA) class (P = 0.02), a
nd a higher incidence of coronary artery disease (P = 0.001) and pulmonary
artery hypertension (P = 0.009). Endocarditis before the primary aortic val
ve replacement (P = 0.004), postoperative pneumonia at the first operation
(P = 0.005), pulmonary hypertension (P = 0.0004) acquired during the interv
al, later recurrence of symptoms (P = 0.04) after the first operation, a lo
wer ejection fraction at the time of reoperation (P = 0.03) and acute onset
of bioprosthetic regurgitation (P = 0.00002) were predictors for emergency
surgery. Higher transvalvular gradients at the primary aortic valve replac
ement (P = 0.006), coronary artery disease (P = 0.003) acquired during the
interval, the need for concomitant coronary artery revascularization (P = 0
,001), sex (P = 0.02) and size (P = 0.05) and type of the bioprostheses use
d (P = 0.007) were incremental predictors for reoperative mortality which w
ere independent of emergency surgery. Conclusions: Elective replacement of
failed aortic bioprostheses is safe. Patients undergoing emergency reoperat
ion have a considerably higher mortality. They can be identified by a histo
ry of native aortic valve endocarditis, higher transvalvular gradients at p
rimary aortic valve replacement, smaller bioprostheses, and pulmonary hyper
tension or coronary artery disease acquired during the interval. A failing
bioprosthesis must be replaced at its first sign of dysfunction. (C) 2000 E
lsevier Science B.V. All rights reserved.