Operative Risk of Reoperative Aortic Valve Replacement

Cardiovascular Surgery

after AVR. Between 1993 and 2001, 162 patients underwent reoperative AVR and 2290 underwent primary AVR; both groups included patients undergoing concomitant coronary artery bypass grafting. The reoperative and primary groups were similar with regard to gender (37% female in both), preoperative New York Heart Association functional class (2.8⫾1 vs. 2.8⫾1) and ejection fraction (58⫾15% vs. 57⫾15%). Patients undergoing reoperative AVR were younger than those undergoing primary AVR (64⫾15 years vs. 70⫾13 years; p⬍0.001). Results: Early mortality for reoperative AVR (8 of 162 patients, 5%) was not statistically different from that for primary AVR (71 of 2290 patients 3%, p⫽0.20). Endocarditis was more common in the reoperative group (22% vs. 3%; p⬍0.001); when endocarditis was excluded from the analysis, early mortality was 3% in both groups. Multivariate predictors for early mortality were prosthetic valve endocarditis (p⬍0.001; odds ratio [OR] 9.8), advanced preoperative functional class (p⬍0.001; OR 2.0), peripheral vascular disease (p⫽0.008; OR 2.0), preserved left ventricular ejection fraction (p⫽0.004; OR 0.98), and male gender (p⫽0.009; OR 0.49). After adjustment for these factors, there was no difference in early mortality between the groups (p⫽0.095). Conclusions: The risk of reoperative AVR is similar to that for primary AVR. Perspective: The risk of “re-do” surgery is used as a rationale to avoid bioprosthesis use in younger patients. However, after controlling for other factors affecting operative risk, it appears that reoperative risks are no different from those associated with first-time surgery. These data support the expanded use of bioprosthetic valves in younger patients. Of note, these data are from a large-volume center and excluded patients beyond a second operative procedure, thus affecting the ability to extrapolate to smaller centers and multiple-time “re-do” surgeries. DB

Abstracts No-Touch Aorta Off-Pump Coronary Surgery: The Effect on Stroke Oren Lev-Ran O, Braunstein R, Sharony R, et al. J Thorac Cardiovasc Surg 2005;129:307–13. Study Question: Is there an effect of avoiding aortic manipulation on major neurologic outcomes after off-pump coronary artery bypass grafting (CABG)? Methods: A total of 700 consecutive patients undergoing multiple-vessel off-pump CABG between 2000 and 2003 were included. The 429 patients undergoing aortic notouch technique were compared with 271 patients in whom partial aortic clamps were applied. The aorta was screened by manual palpation, and epi-aortic ultrasonography was used selectively. Results: The frequency of detected atherosclerotic aortic disease was higher in the no-touch group (17.4% vs. 5.1%; p⬍0.0001). No-touch revascularization was achieved with arterial conduits, arranged in T-graft or in situ configurations (50%). The respective graft/patient ratios were 2.5⫾0.6 and 2.6⫾0.6 in the side-clamp and no-touch groups (p⫽0.009); however, revascularization of the posterolateral myocardial territory was comparable (87% vs. 90%; p⫽NS). The incidence of stroke (0.2% vs. 2.2%; p⫽0.01) was significantly lower in the no-touch group (1 of 429 patients). Logistic regression identified partial aortic clamping as the only independent predictor of stroke (odds ratio 28.5; confidence interval 0.22–333; p⫽0.009). Peripheral vascular disease (p⫽0.068), diabetes (p⫽0.072) and history of stroke (p⫽0.074) also trended an association toward stroke. Conclusions: Avoiding partial aortic clamping during offpump CABG provides superior neurologic outcome. The results are reproducible and irrespective of the severity of aortic disease or the method of aortic screening. Perspective: Studies examining the neuroprotective effects of off-pump CABG have shown inconsistent results, although most studies have not differentiated between clampless and clamp off-pump techniques. These data suggest there may be an advantage in neurologic outcomes in avoiding aortic clamping with off-pump bypass grafting. DB

Survival After Aortic Valve Replacement for Aortic Stenosis: Does Left Ventricular Mass Regression Have a Clinical Correlate? Gaudino M, Alessandrini F, Glieca F, et al. Eur Heart J 2005;26: 51–7. Study Question: What are the effects of left ventricular (LV) mass regression on clinical outcome after aortic valve replacement (AVR) for aortic stenosis? Methods: At a single institution in Europe, 260 consecutive patients who underwent AVR for aortic stenosis were followed prospectively for 28⫾9 months. Clinical characteristics, LV mass and change in LV mass were tested for association with survival by uni- and multivariable analyses. Results: There were 10 deaths before and 52 deaths after hospital discharge. Mean LV mass index decreased from

Operative Risk of Reoperative Aortic Valve Replacement Potter DD, Sundt TM III, Zehr KJ, et al. J Thorac Cardiovasc Surg 2005;129:94 –103. Study Question: What is the relative risk of “re-do” compared with first-time aortic valve replacement (AVR)? Methods: Prospectively collected data from a single large institution were retrospectively reviewed for early mortality

ACC CURRENT JOURNAL REVIEW May 2005

42