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

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. Copyright © 2014 by The American Association for Thoracic Surgery.