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. 2024 May 22:21:45-57.
doi: 10.1016/j.xjon.2024.05.003. eCollection 2024 Oct.

Reoperation after aortic root replacement and its impact on long-term survival

Elizabeth L Norton  1 , Parth M Patel  1 , Yanhua Wang  2 , Jose Binongo  2 , Dov Levine  3 , Sameer Singh  3 , Shreya Chodisetty  1 , Oreoluwa E Olakunle  1 , Bradley G Leshnower  1 , Hiroo Takayama  3 , Edward P Chen  4
Affiliations

Reoperation after aortic root replacement and its impact on long-term survival

Elizabeth L Norton et al. JTCVS Open. .

Abstract

Objective: Reoperation after aortic root replacement (ARR) is associated with increased operative risk and complexity. This study evaluated clinical outcomes and reoperation rates in patients undergoing ARR.

Methods: From 2004 to 2021, 2700 adult patients underwent an ARR in a 2-institution database. Among 2542 surviving patients, 705 patients who had a history of previous cardiac surgery as well as 11 patients who underwent transcatheter aortic valve replacement after index ARR were excluded. Among the finalized cohort of 1826 patients, 88 (4.8%) underwent a reoperation (REDO) on the aortic valve or proximal aorta (root/ascending) a mean of 3.1 years after index ARR whereas 1738 (95%) did not undergo reoperation (no-REDO). A subgroup analysis was performed among those undergoing reoperation by indication including valve dysfunction (48%), endocarditis/graft infection (33%), and aortic aneurysm/dissection/rupture (12%). Reoperative indication was unknown in 6 patients (7%).

Results: The REDO group was younger at time of index ARR (52 vs 58 years, P < .0001) and had more bicuspid aortic valves (56% vs 37%, P = .0003). Most patients underwent modified Bentall ARR (61%), whereas 38% underwent a valve-sparing root replacement. Index root operations were similar between groups. At time of reoperation, 53% underwent aortic valve replacement and 35% underwent redo root replacement. Long-term survival was similar between REDO and no-REDO groups (80% vs 85%, P = .26) and reoperation was not a risk factor for late mortality (hazard ratio, 1.31; P = .26); however, REDO ARR was a risk factor for late mortality (hazard ratio, 2.41; P = .02).

Conclusions: The incidence of aortic valve and/or proximal aorta reoperation after index ARR is relatively low at 4.8%; however, root reoperation is a risk factor for late mortality.

Keywords: aorta; aortic dissection; aortic root replacement; endocarditis; redo-root replacement; reoperation; valve-sparing aortic root replacement.

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Conflict of interest statement

The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Figures

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Graphical abstract
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Proximal aortic reoperation after root replacement does not impact long-term survival.
Figure 1
Figure 1
Consolidated Standards of Reporting Trials diagram of the study population. TAVR, Transcatheter aortic valve replacement.
Figure 2
Figure 2
Long-term survival. A, Kaplan-Meier survival analysis of patients requiring reoperation (n = 88) compared with those without reoperation (n = 1738) after index aortic root replacement. Ten-year survival was similar between reoperation (80%; 95% CI, 69%-87%) and no reoperation (85%; 95% CI, 82%-87%]) groups (P = .26). B, Kaplan-Meier survival analysis of patients requiring reoperation (n = 88) by reoperation indication after index aortic root replacement. Ten-year survival was worse among patients requiring reoperation for endocarditis/graft infection (48%; 95% CI, 27%-66%) and for aortic aneurysm/dissection/rupture (89%; 95% CI, 43%-98%) compared with reoperation for valve dysfunction (95%; 95% CI, 80%-99%]) groups (P = .0002). C, Kaplan-Meier survival analysis of patients requiring reoperation (n = 99) by reoperation indication following reoperation. Eight-year survival was worse among patients requiring reoperation for endocarditis/graft infection (42%; 95% CI, 20%-63%) compared with reoperation for valve dysfunction (92%; 95% CI, 77%-97%) and aortic aneurysm/dissection/rupture (91%; 95% CI, 51%-99%) groups (P = .01). CI, Confidence interval.
Figure 3
Figure 3
Indications for reoperation by index aortic root.
Figure 4
Figure 4
Incidence of reoperation on the aortic valve or proximal aorta after aortic root replacement (ARR) was 4.8% and did not impact long-term survival. TAVR, Transcatheter aortic valve replacement; BAV, bicuspid aortic valve.
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