Aortic valve replacement after previous heart surgery in high-risk patients: transapical aortic valve implantation versus conventional aortic valve replacement-a risk-adjusted and propensity score-based analysis.

OBJECTIVE: Cardiac reoperations have been associated with increased morbidity and mortality compared with first-time surgery. We analyzed our experience with reoperative aortic valve replacement (redo-AVR) and compared these results with those from patients who had undergone transapical aortic valve implantation (TA-AVI) as a second heart operation.

METHODS: In the present retrospective observational comparative study, we analyzed the outcome of 136 patients with previous cardiac surgery who had undergone conventional redo-AVR (n = 59; since 2006) or TA-AVI (n = 77; since 2008) with respect to the 30-day outcomes (Valve Academic Research Consortium criteria), 1- and 3-year survival, and the risk factors for both approaches after previous heart surgery.

RESULTS: Neither group differed significantly in their risk profile, leading to similar Society of Thoracic Surgeon score and EuroSCORE. The 30-day mortality was 3.39% (n = 2) in the redo-AVR group and 7.8% (n = 6) in the redo TA-AVI group (P = .465). The overall combined safety endpoint at 30 days was significantly lower for the TA-AVI patients (18.1% vs 33.9% in redo-AVR; P = .036). The unadjusted and adjusted 1-year survival showed no difference between the 2 groups. The unadjusted 3-year survival revealed a 2.1-fold greater mortality risk after TA-AVI (P = .055). Adjustment by multivariate Cox regression analysis (hazard ratio, 1.427; 95% confidence interval, 0.635-3.209; P = .389) and propensity score (hazard ratio, 1.571; 95% confidence interval, 0.575-4.291; P = .378) led to a >50% risk reduction, resulting in similar 3-year survival in the 2 groups.

CONCLUSIONS: Redo-AVR can be performed with acceptable results in high-risk patients and still serves as the reference standard. Reoperative valve surgery by TA-AVI is feasible and results in comparable short- and mid-term survival.