Log in to MyACC
Redo Aortic Valve Surgery: Influence of Prosthetic Valve Endocarditis on Outcomes
Study Questions:
What are the contemporary risks and long-term outcomes of reoperation for aortic prosthetic valve endocarditis (PVE)?
Methods:
Between December 1994 and April 2008, 313 patients underwent reoperative aortic valve replacement, of whom 152 (48.6%) had PVE. Mean follow-up was 6.5 ± 0.4 years, and 97.4% were complete. Event-free survival was calculated by Kaplan-Meier methods. Independent predictors of long-term survival were determined using Cox proportional hazards analysis.
Results:
Patients with PVE were older with a higher risk profile. The overall hospital mortality was 15.3% (n = 48) (PVE vs. nonendocarditis: 24.3%, n = 37, vs. 6.8%, n = 11; p < 0.001). Independent predictors of perioperative mortality for PVE were sepsis (odds ratio [OR], 6.5; 95% confidence interval [CI], 2.0-21.0; p < 0.01), ejection fraction <30% (OR, 5.8; 95% CI, 1.3-25.0; p = 0.02), concomitant coronary artery bypass grafting (OR, 3.3; 95% CI, 1.1-9.8; p = 0.03), and aortic root abscess (OR, 2.7; 95% CI, 1.2-6.4; p = 0.02), and for the nonendocarditis group were concomitant coronary artery bypass grafting (OR, 8.1; 95% CI, 2.0-33.0; p < 0.01), and mitral valve surgery (OR, 4.8; 95% CI, 1.3-17.9; p = 0.02). The 1-, 3-, 5-, and 10-year survivals for patients with and without PVE were 52% ± 4% versus 82% ± 3%, 43% ± 5% versus 73% ± 4%, 37% ± 5% versus 63% ± 5%, and 31% ± 7% versus 56% ± 8%, respectively (log rank < 0.001). Predictors of long-term mortality in PVE were sepsis (OR, 3.1; 95% CI, 1.5-4.5; p < 0.01) and unstable preoperative status (OR, 1.8; 95% CI, 1.2-3.5; p = 0.04), whereas in nonendocarditis patients, the only predictor was New York Heart Association class IV (OR, 2.5; 95% CI, 2.8-7.4; p < 0.01). Five-year actuarial freedom from endocarditis was 80% ± 0.3% versus 95% ± 0.6% (PVE vs. nonendocarditis; p = 0.002).
Conclusions:
The authors concluded that reoperation for aortic PVE is still associated with relatively high perioperative mortality and limited long-term survival.
Perspective:
This study demonstrates high mortality and poor mid- and long-term survival for patients with aortic PVE undergoing surgical intervention despite contemporary medical and surgical treatment, underlining the fact that treatment of this group of patients still remains a therapeutic challenge. High-risk subgroups include those with sepsis, periannular complications, poor left ventricular function, and those requiring concomitant coronary artery bypass grafting. Long-term survival is worse in those with sepsis or instability before the operation. These factors may have implications for the assessment of an individual patient’s suitability for reoperative surgery.
Keywords: Heart Valve Prosthesis, Endocarditis, Follow-Up Studies, Reoperation, Hospital Mortality, Ventricular Function, Left, Disease-Free Survival, Coronary Artery Bypass, New York, Mitral Valve
< Back to Listings
