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.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention

Keywords: Heart Valve Prosthesis, Endocarditis, Follow-Up Studies, Reoperation, Hospital Mortality, Ventricular Function, Left, Disease-Free Survival, Coronary Artery Bypass, New York, Mitral Valve


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