Conventional redo biological valve replacement over 20 years

Surgical benchmarks should guide patient selection for transcatheter valve-in-valve therapy

John M. Stulak, Vakhtang Tchantchaleishvili, Richard C. Daly, Mackram Eleid, Kevin L. Greason, Joseph A. Dearani, Lyle D. Joyce, Alberto Pochettino, Hartzell V Schaff, Simon Maltais

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

Objectives: Although primary transcatheter valve interventions have demonstrated acceptable early- and intermediate-term outcomes, data are lacking to guide patient selection for transcatheter valve-in-valve therapy. Furthermore, very few surgical benchmarks have been established for repeat conventional biological valve replacement to refine momentum for broad application of transcatheter intervention for a degenerated bioprosthesis. Methods: From January 1993 to July 2014, 694 patients underwent repeat biological valve replacement at our clinic. Median age at repeat operation was 71 years (range, 26-95 years) and there were 437 men (63%). Hypertension was present in 453 patients (65%), diabetes in 128 patients (18%), prior myocardial infarction in 85 patients (12%), and prior stroke in 81 patients (12%). Prior coronary bypass grafting was performed in 212 patients (31%). Median left ventricular ejection fraction was 41% (range, 20-61) and New York Heart Association functional class III or IV was present in 529 patients (76%). Results: Biological valve re-replacement included most commonly aortic valve in 464 patients (67%) and mitral valve in 170 (24%). Concomitant coronary bypass grafting was performed in 134 patients (19%). Mortality at 30 days occurred in 56 patients (8%). Multivariable analysis with backward stepwise regression identified New York Heart Association functional class (per 1 increment) (hazard ratio, 2.1; 95% confidence interval, 1.06-4.3; P =.03) and prior coronary bypass grafting (hazard ratio, 3.5; 95% confidence interval, 1.2-10.9; P =.03) as independent predictors of early death. Patients with the combination of prior coronary bypass grafting and New York Heart Association functional class III or IV accounted for 26 out of 56 early deaths (46%) and in the absence of this combination, early death in the cohort was 30 out of 694 (4%). Follow-up was available in 602 out of 638 early survivors (94%) for a median of 45 months (range, 1 month-23.4 years). Survival at 5 and 10 years was 63% and 34%, respectively. For patients who died during follow-up, 2-dimensional scatter plots demonstrate durable length of postoperative survival (median, 5.5 years; maximum, 22 years). Conclusions: In a large population of patients undergoing repeat biological valve replacement, prior coronary bypass grafting and advanced New York Heart Association functional class were associated with increased 30-day mortality, with the remaining population having a low 30-day mortality of 4%. This study could serve as a surgical benchmark to guide patient selection for transcatheter valve-in-valve technology rather than employing a broader application of these techniques to those who may otherwise have low early risk of mortality and durable long-term survival after conventional valve surgery.

Original languageEnglish (US)
Pages (from-to)1380-1390.e1
JournalJournal of Thoracic and Cardiovascular Surgery
Volume156
Issue number4
DOIs
StatePublished - Oct 1 2018

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Benchmarking
Patient Selection
Therapeutics
Mortality
Survival
Confidence Intervals
Bioprosthesis
Aortic Valve
Mitral Valve
Stroke Volume
Population
Survivors

Keywords

  • bioprosthesis
  • valve replacement
  • valve-in-valve

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

Conventional redo biological valve replacement over 20 years : Surgical benchmarks should guide patient selection for transcatheter valve-in-valve therapy. / Stulak, John M.; Tchantchaleishvili, Vakhtang; Daly, Richard C.; Eleid, Mackram; Greason, Kevin L.; Dearani, Joseph A.; Joyce, Lyle D.; Pochettino, Alberto; Schaff, Hartzell V; Maltais, Simon.

In: Journal of Thoracic and Cardiovascular Surgery, Vol. 156, No. 4, 01.10.2018, p. 1380-1390.e1.

Research output: Contribution to journalArticle

Stulak, John M. ; Tchantchaleishvili, Vakhtang ; Daly, Richard C. ; Eleid, Mackram ; Greason, Kevin L. ; Dearani, Joseph A. ; Joyce, Lyle D. ; Pochettino, Alberto ; Schaff, Hartzell V ; Maltais, Simon. / Conventional redo biological valve replacement over 20 years : Surgical benchmarks should guide patient selection for transcatheter valve-in-valve therapy. In: Journal of Thoracic and Cardiovascular Surgery. 2018 ; Vol. 156, No. 4. pp. 1380-1390.e1.
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abstract = "Objectives: Although primary transcatheter valve interventions have demonstrated acceptable early- and intermediate-term outcomes, data are lacking to guide patient selection for transcatheter valve-in-valve therapy. Furthermore, very few surgical benchmarks have been established for repeat conventional biological valve replacement to refine momentum for broad application of transcatheter intervention for a degenerated bioprosthesis. Methods: From January 1993 to July 2014, 694 patients underwent repeat biological valve replacement at our clinic. Median age at repeat operation was 71 years (range, 26-95 years) and there were 437 men (63{\%}). Hypertension was present in 453 patients (65{\%}), diabetes in 128 patients (18{\%}), prior myocardial infarction in 85 patients (12{\%}), and prior stroke in 81 patients (12{\%}). Prior coronary bypass grafting was performed in 212 patients (31{\%}). Median left ventricular ejection fraction was 41{\%} (range, 20-61) and New York Heart Association functional class III or IV was present in 529 patients (76{\%}). Results: Biological valve re-replacement included most commonly aortic valve in 464 patients (67{\%}) and mitral valve in 170 (24{\%}). Concomitant coronary bypass grafting was performed in 134 patients (19{\%}). Mortality at 30 days occurred in 56 patients (8{\%}). Multivariable analysis with backward stepwise regression identified New York Heart Association functional class (per 1 increment) (hazard ratio, 2.1; 95{\%} confidence interval, 1.06-4.3; P =.03) and prior coronary bypass grafting (hazard ratio, 3.5; 95{\%} confidence interval, 1.2-10.9; P =.03) as independent predictors of early death. Patients with the combination of prior coronary bypass grafting and New York Heart Association functional class III or IV accounted for 26 out of 56 early deaths (46{\%}) and in the absence of this combination, early death in the cohort was 30 out of 694 (4{\%}). Follow-up was available in 602 out of 638 early survivors (94{\%}) for a median of 45 months (range, 1 month-23.4 years). Survival at 5 and 10 years was 63{\%} and 34{\%}, respectively. For patients who died during follow-up, 2-dimensional scatter plots demonstrate durable length of postoperative survival (median, 5.5 years; maximum, 22 years). Conclusions: In a large population of patients undergoing repeat biological valve replacement, prior coronary bypass grafting and advanced New York Heart Association functional class were associated with increased 30-day mortality, with the remaining population having a low 30-day mortality of 4{\%}. This study could serve as a surgical benchmark to guide patient selection for transcatheter valve-in-valve technology rather than employing a broader application of these techniques to those who may otherwise have low early risk of mortality and durable long-term survival after conventional valve surgery.",
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T2 - Surgical benchmarks should guide patient selection for transcatheter valve-in-valve therapy

AU - Stulak, John M.

AU - Tchantchaleishvili, Vakhtang

AU - Daly, Richard C.

AU - Eleid, Mackram

AU - Greason, Kevin L.

AU - Dearani, Joseph A.

AU - Joyce, Lyle D.

AU - Pochettino, Alberto

AU - Schaff, Hartzell V

AU - Maltais, Simon

PY - 2018/10/1

Y1 - 2018/10/1

N2 - Objectives: Although primary transcatheter valve interventions have demonstrated acceptable early- and intermediate-term outcomes, data are lacking to guide patient selection for transcatheter valve-in-valve therapy. Furthermore, very few surgical benchmarks have been established for repeat conventional biological valve replacement to refine momentum for broad application of transcatheter intervention for a degenerated bioprosthesis. Methods: From January 1993 to July 2014, 694 patients underwent repeat biological valve replacement at our clinic. Median age at repeat operation was 71 years (range, 26-95 years) and there were 437 men (63%). Hypertension was present in 453 patients (65%), diabetes in 128 patients (18%), prior myocardial infarction in 85 patients (12%), and prior stroke in 81 patients (12%). Prior coronary bypass grafting was performed in 212 patients (31%). Median left ventricular ejection fraction was 41% (range, 20-61) and New York Heart Association functional class III or IV was present in 529 patients (76%). Results: Biological valve re-replacement included most commonly aortic valve in 464 patients (67%) and mitral valve in 170 (24%). Concomitant coronary bypass grafting was performed in 134 patients (19%). Mortality at 30 days occurred in 56 patients (8%). Multivariable analysis with backward stepwise regression identified New York Heart Association functional class (per 1 increment) (hazard ratio, 2.1; 95% confidence interval, 1.06-4.3; P =.03) and prior coronary bypass grafting (hazard ratio, 3.5; 95% confidence interval, 1.2-10.9; P =.03) as independent predictors of early death. Patients with the combination of prior coronary bypass grafting and New York Heart Association functional class III or IV accounted for 26 out of 56 early deaths (46%) and in the absence of this combination, early death in the cohort was 30 out of 694 (4%). Follow-up was available in 602 out of 638 early survivors (94%) for a median of 45 months (range, 1 month-23.4 years). Survival at 5 and 10 years was 63% and 34%, respectively. For patients who died during follow-up, 2-dimensional scatter plots demonstrate durable length of postoperative survival (median, 5.5 years; maximum, 22 years). Conclusions: In a large population of patients undergoing repeat biological valve replacement, prior coronary bypass grafting and advanced New York Heart Association functional class were associated with increased 30-day mortality, with the remaining population having a low 30-day mortality of 4%. This study could serve as a surgical benchmark to guide patient selection for transcatheter valve-in-valve technology rather than employing a broader application of these techniques to those who may otherwise have low early risk of mortality and durable long-term survival after conventional valve surgery.

AB - Objectives: Although primary transcatheter valve interventions have demonstrated acceptable early- and intermediate-term outcomes, data are lacking to guide patient selection for transcatheter valve-in-valve therapy. Furthermore, very few surgical benchmarks have been established for repeat conventional biological valve replacement to refine momentum for broad application of transcatheter intervention for a degenerated bioprosthesis. Methods: From January 1993 to July 2014, 694 patients underwent repeat biological valve replacement at our clinic. Median age at repeat operation was 71 years (range, 26-95 years) and there were 437 men (63%). Hypertension was present in 453 patients (65%), diabetes in 128 patients (18%), prior myocardial infarction in 85 patients (12%), and prior stroke in 81 patients (12%). Prior coronary bypass grafting was performed in 212 patients (31%). Median left ventricular ejection fraction was 41% (range, 20-61) and New York Heart Association functional class III or IV was present in 529 patients (76%). Results: Biological valve re-replacement included most commonly aortic valve in 464 patients (67%) and mitral valve in 170 (24%). Concomitant coronary bypass grafting was performed in 134 patients (19%). Mortality at 30 days occurred in 56 patients (8%). Multivariable analysis with backward stepwise regression identified New York Heart Association functional class (per 1 increment) (hazard ratio, 2.1; 95% confidence interval, 1.06-4.3; P =.03) and prior coronary bypass grafting (hazard ratio, 3.5; 95% confidence interval, 1.2-10.9; P =.03) as independent predictors of early death. Patients with the combination of prior coronary bypass grafting and New York Heart Association functional class III or IV accounted for 26 out of 56 early deaths (46%) and in the absence of this combination, early death in the cohort was 30 out of 694 (4%). Follow-up was available in 602 out of 638 early survivors (94%) for a median of 45 months (range, 1 month-23.4 years). Survival at 5 and 10 years was 63% and 34%, respectively. For patients who died during follow-up, 2-dimensional scatter plots demonstrate durable length of postoperative survival (median, 5.5 years; maximum, 22 years). Conclusions: In a large population of patients undergoing repeat biological valve replacement, prior coronary bypass grafting and advanced New York Heart Association functional class were associated with increased 30-day mortality, with the remaining population having a low 30-day mortality of 4%. This study could serve as a surgical benchmark to guide patient selection for transcatheter valve-in-valve technology rather than employing a broader application of these techniques to those who may otherwise have low early risk of mortality and durable long-term survival after conventional valve surgery.

KW - bioprosthesis

KW - valve replacement

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