Re-do aortic valve replacement after previous homograft aortic root replacement

Transcription

1 Re-do aortic valve replacement after previous homograft aortic root replacement Jullien Gaer, Toufan Bahrami, Fabio de Robertis, Ahmed Abdulsalam, John Pepper, NHS Foundation Trust, UK

2 Professor Sir Magdi Yacoub OM, FRS

3 Background Cardiac surgical opinion remains divided over the use of aortic homografts Pros Tissue handling Haemostasis Resistance to infection Cons Availability Implantation Complexity of redo operation Most reports of non-inferiority of mechanical valves/stented bioprostheses are underpowered with relatively high early mortality

4 Pettersson et al (2017) 2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: Surgical treatment of infective endocarditis: Executive summary J Thorac Cardiovasc Surg 153: Native valve IE CoR LoE For invasive and destructive native aortic valve IE requiring root reconstruction and replacement, using an allograft may be beneficial, but a prosthetic bioroot or prosthetic valved conduit with a mechanical or bioprosthetic valve are acceptable alternatives, with choice guided by surgeon training and experience IIa B Prosthetic valve IE If there is annulus destruction and invasion outside the aortic root and root reconstruction and replacement is required, an allograft or a biologic tissue root is preferable to a prosthetic valved conduit IIa B

5 McGiffin et al (1992) Aortic valve infection. Risk factors for death and recurrent endocarditis after aortic valve replacement. J Thorac Cardiovasc Surg 104:

6 Hussain et al (2017) Challenging allograft use for aortic valve infective endocarditis: Is it the allograft or the surgeon? J Thorac Cardiovasc Surg 153:280-1 Hussain et al (2017) Allografts remain a cornerstone of surgical treatment of invasive and destructive aortic valve infective endocarditis: Surgeon and technique do matter! J Thorac Cardiovasc Surg 154:1900-1

7 Calcified homograft 10 years post-op

8 Calcified homograft 12 years post-op

9 Re-do aortic valve replacement after previous homograft aortic root replacement Retrospective study of the outcome of re-do aortic valve surgery in patients who had previously undergone homograft aortic root replacement The data were obtained from the Trust s returns to NICOR (National Institute for Cardiovascular Research Outcomes) Long-term survival data cross-checked with the NHS Spine Data are presented as mean ± standard error of the mean (μ±sem)

10 Demographics Between 1998 & 2016, 318 patients were eligible for inclusion in the analysis Age 56±4.5 years Sex ratio M:F = 231:87 (2.7:1 ) Freedom from re-intervention: 11.8 ± 0.94 yrs

11 Operative urgency Status Patients (n) % Elective Urgent Emergency patients (6%) were recorded as having active infective endocarditis at the time of surgery

12 Previous sternotomies No. of previous sternotomies Patients (n) %

13 Choice of aortic valve replacement Procedure Patients (n) % Mechanical AVR Stented bioprosthesis Homograft Stentless bioprosthetic root Pulmonary autograft 11 4 Rapid deployment bioprosthesis 2 Mechanical Bentall 1

14 Cardiopulmonary bypass μ SEM Cross-clamp time (min) Total CPB time (min) patients required mechanical circulatory support with either Levitronix or ECMO Concomitant procedures 79 patients underwent one or more concomitant procedures including CABG, MVR/MV rep, other aortic procedures

15 Survival 30-day all cause/hospital mortality was 5.7% (18 patients) Median duration of follow-up was 9.2 years

16 Probability Kaplan-Meier survival curve Time (years) Year No at risk

17 Actuarial survival Years %

18 Duncan et al (2015) Valve-in-valve transcatheter aortic valve implantation for failing surgical aortic stentless bioprosthetic valves: A single-center experience J Thorac Cardiovasc Surg 150: patients (17 homografts, 3 SPV, 1 Freestyle, 1 David) TAVR with CoreValve Device migration in 3 cases No early deaths 14% mortality at one year

19 Conclusions Redo AVR after homograft aortic root replacement can be a daunting operation but can be accomplished with good short- and long-term outcomes A versatile operative strategy is required in order to deal with the calcified aortic root Concern about the complexity of the subsequent redo operation should not preclude homograft use when otherwise indicated, particularly in endocarditis TAVR has an increasing role in all redo AVR surgery

20 CB 52y m Congenital bicuspid valve Valvotomy in childhood Lost to follow-up and represented in 2016 with severe AS S. aureus grown in blood but patient well, with normal serum markers, afebrile with normal WCC

21 25 mm CE stented bioprosthesis Uneventful surgery TOE in theatre showed no PVL Uneventful 1 st 12 hours Overnight became profoundly vasoplegic and febrile CB 52y m

22 Emergency aortic root replacement on Day 1 post-op Uneventful course thereafter On IV antibiotics for 6 weeks CB 52y m