Reoperation After Prior Aortic Root Replacement: Evolution of Technique Over 30 Years
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0280
Submission Type:
Abstract Submission
Authors:
Anna Xue (1), Lynna Nguyen (2), Susan Green (3), Ginger Etheridge (2), Subhasis Chatterjee (4), Lauren Barron (2), vicente Orozco Sevilla (5), Marc Moon (6), Joseph Coselli (7)
Institutions:
(1) Baylor College of Medicine/Texas Heart Institute, Houston, TX, (2) Baylor College of Medicine, Houston, TX, (3) N/A, Houston, TX, (4) Baylor St. Luke's Medical Center, Houston, TX, (5) Baylor St Lukes/Texas Heart Institute, Houston, TX, (6) Baylor College of Medicine / Texas Heart Institute, Houston, TX, (7) Baylor College of Medicine, Texas Heart Institute, United States
Submitting Author:
Anna Xue
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Baylor College of Medicine/Texas Heart Institute
Baylor College of Medicine/Texas Heart Institute
Co-Author(s):
Lynna Nguyen
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Baylor College of Medicine
Baylor College of Medicine
Susan Green
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N/A
N/A
Ginger Etheridge
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Baylor College of Medicine
Baylor College of Medicine
*Subhasis Chatterjee
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Baylor St. Luke's Medical Center
Baylor St. Luke's Medical Center
Lauren Barron
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Baylor College of Medicine
Baylor College of Medicine
Vicente Orozco-Sevilla
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Baylor St Lukes/Texas Heart Institute
Baylor St Lukes/Texas Heart Institute
*Marc Moon
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Baylor College of Medicine / Texas Heart Institute
Baylor College of Medicine / Texas Heart Institute
*Joseph Coselli
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Baylor College of Medicine, Texas Heart Institute
Baylor College of Medicine, Texas Heart Institute
Presenting Author:
Anna Xue
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UC Davis Medical Center
UC Davis Medical Center
Abstract:
Objective: Aortic root replacement (ARR) with a valve-replacing mechanical valve conduit is a longstanding cornerstone for treating aortic root aneurysm-emerging techniques include bioprosthetic and valve-sparing (VS) approaches. However, the durability of ARR may be compromised and failure of the valve or root complex can necessitate late repair in some patients. We describe our experience with reoperation in patients with prior ARR, emphasizing indications for reintervention, types of subsequent repair, and outcomes of reoperative repair.
Methods: In a retrospective analysis of patients undergoing elective reoperation related to previous ARR, we identified a final population of 193 such patients undergoing repair between 1991 and 2023. We divided patients into three intervention subgroups: true redo ARR (n=132), surgical aortic valve replacement (SAVR; n=40), and transcatheter aortic valve replacement (TAVR; n=21).
Results: The median patient age was 54 years (range, 41-62); patients undergoing TAVR were older (true redo ARR: 53 [39-61]; SAVR: 54 [43-67]; TAVR: 63 [52-73]; p=0.2). Few significant differences in baseline demographics were seen among the three subgroups such as the chronicity of symptoms at presentation. Indications for reintervention included prosthetic valve regurgitation (94/193), pseudoaneurysm (55/193), and graft infection (46/193). Prior ARR techniques included a mechanical composite valve graft (CVG) in 74 patients, of which 71 underwent a subsequent redo ARR (Figure). Additionally, 28 patients underwent an index aortic valve sparing root replacement and 91 patients had an index bioprosthetic root with many of these patients undergoing a true redo ARR (51/91) and the rest a valve replacement only (SAVR [n=18/91] and TAVR [n=19/91]). Repair was urgent or emergent in 39% (n=76). Aortic disease necessitated hemiarch or total arch replacement during reintervention in 92 patients (48%). Overall operative mortality was 14%, which differed with the approach to repair (true redo ARR: 19%; SAVR: 5%; TAVR: 0%; p=0.01). Persistent stroke occurred in only 5 patients (3%), although cardiac complications (including arrhythmia, cardiac failure, and pericardial effusion) were more common (n=81; 42%). The length of overall hospital stay was lower after TAVR (3 days [2-4.5]) compared to after true redo ARR (10 days [7-16]) and SAVR (10 days [7-20]; p<0.001). In late events, survival differed by approach (p=0.003); at 5 years, survival was 100% after TAVR, and at 10 years, was 48%±6% and 68%±10% after true redo ARR and SAVR, respectively. Recurrent repair failure was relatively uncommon; at 5 years, freedom from recurrent repair failure was 100% after TAVR and was 86%±7% and 73%±12% at 10 years after true redo ARR and SAVR, respectively.
Conclusions: In general, the approach to reintervention after prior ARR is dictated by the indication for repair, with true redo ARR indicated by complex reoperative scenarios (e.g., infection or pseudoaneurysm). Operative mortality trended higher with true redo ARR than with SAVR, which is not unexpected given the technical demands of redo aortic root intervention. When suitable, emerging TAVR techniques are beneficial to avoid redo sternotomy, with minimal operative mortality and a short length of stay.
Methods: In a retrospective analysis of patients undergoing elective reoperation related to previous ARR, we identified a final population of 193 such patients undergoing repair between 1991 and 2023. We divided patients into three intervention subgroups: true redo ARR (n=132), surgical aortic valve replacement (SAVR; n=40), and transcatheter aortic valve replacement (TAVR; n=21).
Results: The median patient age was 54 years (range, 41-62); patients undergoing TAVR were older (true redo ARR: 53 [39-61]; SAVR: 54 [43-67]; TAVR: 63 [52-73]; p=0.2). Few significant differences in baseline demographics were seen among the three subgroups such as the chronicity of symptoms at presentation. Indications for reintervention included prosthetic valve regurgitation (94/193), pseudoaneurysm (55/193), and graft infection (46/193). Prior ARR techniques included a mechanical composite valve graft (CVG) in 74 patients, of which 71 underwent a subsequent redo ARR (Figure). Additionally, 28 patients underwent an index aortic valve sparing root replacement and 91 patients had an index bioprosthetic root with many of these patients undergoing a true redo ARR (51/91) and the rest a valve replacement only (SAVR [n=18/91] and TAVR [n=19/91]). Repair was urgent or emergent in 39% (n=76). Aortic disease necessitated hemiarch or total arch replacement during reintervention in 92 patients (48%). Overall operative mortality was 14%, which differed with the approach to repair (true redo ARR: 19%; SAVR: 5%; TAVR: 0%; p=0.01). Persistent stroke occurred in only 5 patients (3%), although cardiac complications (including arrhythmia, cardiac failure, and pericardial effusion) were more common (n=81; 42%). The length of overall hospital stay was lower after TAVR (3 days [2-4.5]) compared to after true redo ARR (10 days [7-16]) and SAVR (10 days [7-20]; p<0.001). In late events, survival differed by approach (p=0.003); at 5 years, survival was 100% after TAVR, and at 10 years, was 48%±6% and 68%±10% after true redo ARR and SAVR, respectively. Recurrent repair failure was relatively uncommon; at 5 years, freedom from recurrent repair failure was 100% after TAVR and was 86%±7% and 73%±12% at 10 years after true redo ARR and SAVR, respectively.
Conclusions: In general, the approach to reintervention after prior ARR is dictated by the indication for repair, with true redo ARR indicated by complex reoperative scenarios (e.g., infection or pseudoaneurysm). Operative mortality trended higher with true redo ARR than with SAVR, which is not unexpected given the technical demands of redo aortic root intervention. When suitable, emerging TAVR techniques are beneficial to avoid redo sternotomy, with minimal operative mortality and a short length of stay.
Aortic Symposium:
Aortic Root
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