Reinterventions after freestyle stentless aortic valve replacement: an assessment of procedural risks

Eur J Cardiothorac Surg. 2019 Dec 1;56(6):1117-1123. doi: 10.1093/ejcts/ezz222.

Abstract

Objectives: Repeat aortic valve interventions after previous stentless aortic valve replacement (AVR) are considered technically challenging with an increased perioperative risk, especially after full-root replacement. We analysed our experience with reinterventions after stentless AVR.

Methods: A total of 75 patients with previous AVR using a Freestyle stentless bioprosthesis (31 subcoronary, 15 root-inclusion and 29 full-root replacement) underwent reintervention in our centre from 1993 until December 2018. Periprocedural data were retrospectively collected from the department database and follow-up data were prospectively collected.

Results: Median age was 62 years (interquartile range 47-72 years). Indications for reintervention were structural valve deterioration (SVD) in 47, non-SVD in 13 and endocarditis in 15 patients. Urgent surgery was required in 24 (32%) patients. Reinterventions were surgical AVR in 16 (21%), root replacement in 51 (68%) and transcatheter AVR in 8 (11%) patients. Early mortality was 9.3% (n = 7), but decreased to zero in the past decade in 28 patients undergoing elective reoperation. Per indication, early mortality was 9% for SVD, 8% for non-SVD and 13% for endocarditis. Aortic root replacement had the lowest early mortality rate (6%), followed by surgical AVR (13%) and transcatheter AVR (25%, 2 patients with coronary artery obstruction). Pacemaker implantation rate was 7%. Overall survival rate at 10 years was 69% (95% confidence interval 53-81%).

Conclusions: Repeat aortic valve interventions after stentless AVR carry an increased, but acceptable, early mortality risk. Transcatheter valve-in-valve procedures after stentless AVR require careful consideration of prosthesis leaflet position to prevent obstruction of the coronary arteries.

Keywords: Aortic root replacement; Aortic valve replacement; Heart valve replacement; Percutaneous; Reoperation.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aortic Valve / surgery*
  • Female
  • Heart Valve Prosthesis / adverse effects*
  • Heart Valve Prosthesis Implantation* / adverse effects
  • Heart Valve Prosthesis Implantation* / instrumentation
  • Heart Valve Prosthesis Implantation* / mortality
  • Humans
  • Male
  • Middle Aged
  • Postoperative Complications / epidemiology
  • Postoperative Complications / mortality
  • Postoperative Complications / surgery
  • Prosthesis Design
  • Reoperation / statistics & numerical data*
  • Retrospective Studies
  • Risk Assessment