[Reoperation after aortic valve replacement and root reconstruction]

Abstract

Between 1984 and 1997, 127 patients in our institution underwent single aortic valve replacement (AVR) with the St. Jude Medical valve (group S) and 11 patients with a porcine pericardial valve (group T). In the same period, 45 patients underwent aortic root reconstruction, among which 39 patients underwent the Bentall procedure using Carrel patch coronary reanastomosis (group B). The other 6 patients were treated with valve-sparing aortic root reconstruction (group V), among which the reimplantation method was used in 4 patients and the remodeling method in 2. The mean and total follow-up periods of the AVR and aortic root reconstruction groups were 6.9 +/- 1.9 year/735 patient-years and 4.9 +/- 3.9/years/196 patient-years respectively. The actuarial overall survival rates in group S and T at 10 years were; 73.8 +/- 7.0% and 85.7 +/- 13.0%, respectively The probabilities of freedom from reoperation at 12 years in group S and T were 97.7 +/- 2.3% and 62.5 +/- 21.3%, respectively. Only one patient in group S required reoperation because of valve thrombosis, while 2 patients in group T underwent reoperation for prosthetic valve endocarditis. The actuarial overall survival rate after aortic root reconstruction at 10 years was 62.6 +/- 9.6%, while that of patients with acute aortic dissection and those who did not were 44.4 +/- 15.7% and 71.7 +/- 11.5%, respectively. The event-free rate at 12 years after aortic root reconstruction (group V+B) was 79.1% +/- 20/9%. The reason for reoperation in the 2 patients who underwent the Bentall procedure were prosthetic valve endocarditis in one and psuedoaneurysm at the right coronary anastomosis in the other. The reason for reoperation in one patient who formed a pseudoaneurysm was likely due to an oversized conduit hole for the Carrel patch coronary anastomosis. One patient in whom the native valve was preserved using the David reimplantation procedure required reoperation because of valve degeneration 17 months after the initial surgery, possibly due to valve rubbing on the vascular conduit because of a modified geometry of the Valsalva sinuses. In conclusion, because of the low rate of long-term mortality and reoperation, the St. Jude Medical valve is an excellent prosthesis for AVR. AVR with a porcine pericardial valve yields favorable results in terms of the low long-term mortality although the incidence of reoperation remains high. Aortic root reconstruction with the Bentall procedure using the Carrel patch method yields acceptable results in terms of long-term mortality and low rate of reoperation, although acute aortic dissection is an incremental preoperative risk factor. The early results of aortic valve-sparing root reconstructive surgery are encouraging, with excellent clinical outcomes and patient quality of life. Nevertheless, the indications for the procedure must be carefully considered.