The Risks and Benefits of Reoperative Aortic Valve Replacement
Background: Many patients are advised to have mechanical aortic valve replacement (AVR) because their expected longevity exceeds that of tissue prostheses. This strategy may avoid the risks of reoperation but exposes patients to the risks of long-term anticoagulation therapy. Which risk is greater?
Methods: We reviewed the records of 1213 consecutive, unselected AVR patients, 60% of whom had concomitant procedures, who were treated from 1994 through 2002. Of these patients, 887 were first-time AVR patients, and 326 underwent reoperation. Of the reoperation patients, 134 had previously undergone AVR (redo). We constructed a risk model from these 1213 cases to assess the factors that predicted mortality and to examine the extent to which reoperation affected outcome.
Results: Multiple logistic regression analysis indicated that factors of reoperation and redo operation did not predict mortality. In fact, the mortality rate was 4.1% for all first AVR operations and 3.1% for all reoperation AVR (P = .891). Significant predicting factors (with odds ratios) were reoperative dialysis (6.03), preoperative shock (3.68), New York Heart Association class IV (2.20), female sex (1.76), age (1.61), and cardiopulmonary bypass time (1.26).
Conclusions: In this series, the risk of reoperation AVR is comparable with the published risks of long-term warfarin sodium (Coumadin) administration after mechanical AVR. Any adult who requires AVR may be well advised to consider tissue prostheses.
Akins CW. 1995. Results with mechanical cardiac valvular prostheses. Ann Thorac Surg 60:1836-44.nAkins CW, Buckley MJ, Daggett WM, et al. 1998. Risk of reoperative valve replacement for failed mitral and aortic bioprostheses. Ann Thorac Surg 65:1545-51.nAkins CW, Hilgenberg AD, Vlahakes GJ, MacGillivray TE, Torchiana DF, Madsen JC. 2002. Results of bioprosthetic versus mechanical aortic valve replacement performed with concomitant coronary artery bypass grafting. Ann Thorac Surg 74:1098-106.nButchart EG, Payne N, Li HH, Buchan K, Maudana K, Grunkemeier GL. 2002. Better anticoagulation control improves survival after valve replacement. J Thorac Cardiovasc Surg 123:715-23.nCarrier M, Pellerin M, Perrault LP, et al. 2001. Aortic valve replacement with mechanical and biologic prosthesis in middle-aged patients. Ann Thorac Surg 71(suppl):S253-6.nDavid TE, Ivanov J, Armstrong S, Feindel CM, Cohen G. 2001. Late results of heart valve replacement with the Hancock II bioprosthesis. J Thorac Cardiovasc Surg 121:268-77.nGrover FL, Hammermeister KE, Burchfiel C. 1990. Initial report of the Veterans Administration Preoperative Risk Assessment Study for Cardiac Surgery. Ann Thorac Surg 50:12-28.nGrunkemeier GL, Jin R. 2001. Receiver operating characteristic curve analysis of clinical risk models. Ann Thorac Surg 72:323-6.nGrunkemeier GL, Wu Y, Furnary AP. 2003. Cumulative sum techniques for assessing surgical results. Ann Thorac Surg 76:663-7.nHammermeister KE, Sethi GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH. 2000. Outcomes 15 years after replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs Randomized Trial. J Am Coll Cardiol 36:1152-8.nHammermeister KE, Sethi GK, Henderson WG, Oprian C, Kim T, Rahimtoola S. 1993. A comparison of outcomes in men 11 years after heart-valve replacement with a mechanical valve or bioprosthesis: Veterans Affairs Cooperative Study on Valvular Heart Disease. N Engl J Med 328:1289-96.nHosmer DW, Lemeshow S. 1980. A goodness-of-fit test for the multiple logistic regression model. Commun Stat A10:1043-69.nKon ND, Riley RD, Adair SM, Kitzman DW, Cordell AR. 2002. Eight-year results of aortic root replacement with the Freestyle stentless porcine aortic root bioprosthesis. Ann Thorac Surg 73:1817-21.nOxenham H, Bloomfield P, Wheatley DJ, et al. 2003. Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart 89:715-21.nPeterstein DS, Cen Y, Cheruvu S, et al. 1999. Long-term outcome after biologic versus mechanical aortic valve replacement in 841 patients. J Thorac Cardiovasc Surg 117:890-7.nRahimtoola SH. 2003. Choice of prosthetic heart valve for adult patients. J Am Coll Cardiol 41:893-904.nSidhu P, O'Kane H, Ali N, et al. 2001. Mechanical or bioprosthetic valves in the elderly: a 20-year comparison. Ann Thorac Surg 71(suppl):S257-60.nTaylor KM. 2003. The Edinburgh heart valve study. Heart 89:697-8.n
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).