Redo surgical aortic valve replacement: An outdated technique in the era of valve-in-valve procedures?

Background: The treatment of degenerative prosthetic aortic valves is increasingly important. However, redo surgical aortic valve replacement (Re-SAVR) carries higher perioperative risks than primary surgical aortic valve replacement.

Aim: This study aims to identify predictors of early morbidity and death after Re-SAVR.

Methods: A retrospective analysis of 220 patients scheduled for elective Re-SAVR between 2009 and 2017 was conducted. Patients were divided into isolated (n=87) and combined (n=133) redo procedures. The primary endpoint was in-hospital death, and secondary endpoints were postoperative complications, such as stroke, dialysis and pacemaker implantation. Regression analysis identified independent predictors of death.

Results: Among the patients undergoing Re-SAVR (mean age, 62.6±13.2years; 71% male; mean EuroSCORE II, 12.6±11.1%), 86.4% received biological prostheses and 13.6% received mechanical prostheses. The in-hospital death rate was 5.7% for isolated Re-SAVR and 18.0% for combined procedures (P=0.003). Excluding patients with endocarditis, the in-hospital death rate was 0% for isolated Re-SAVR and 19.7% for combined procedures (P=0.002). The incidence of postoperative complications after an isolated procedure was similar to that after a combined procedure. Independent predictors of 30-day death were previous coronary artery bypass grafting (odds ratio: 14.12, 95% confidence interval: 4.40-51.35; P<0.001), a combined procedure (odds ratio: 7.01, 95% confidence interval: 2.09-31.54; P=0.004) and New York Heart Association functional class III/IV (odds ratio: 3.73, 95% confidence interval: 1.31-12.58; P=0.020).

Conclusions: The perioperative risk of death after isolated Re-SAVR in patients without endocarditis was 0%. Independent predictors of in-hospital death included previous coronary artery bypass grafting, combined procedures and New York Heart Association class III/IV. These findings may inform the decision-making process of the heart team regarding the optimal approach (surgical or transcatheter) for redo aortic valve replacement.