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Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Aortic Unit, Royal Brompton & Harefield NHS Foundation Trust, UK
Re-do aortic valve replacement after previous homograft aortic root
replacement
Jullien Gaer, Toufan Bahrami, Fabio de Robertis, Ahmed Abdulsalam, John Pepper
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Professor Sir Magdi Yacoub OM, FRS
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Background
Cardiac surgical opinion remains divided over the use of aortic homografts
Pros Cons
Tissue handling Availability
Haemostasis Implantation
Resistance to infection Complexity of redo operation
Most reports of non-inferiority of mechanical valves/stented bioprostheses are underpowered with relatively high early mortality
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Pettersson et al (2017) 2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: Surgical treatment of infective endocarditis: Executive summary J Thorac Cardiovasc Surg 153:1241-1258
Native valve IE CoR LoE
For invasive and destructive native aortic valve IE requiring root reconstruction and replacement, using an allograft may be beneficial, but a prosthetic bioroot or prosthetic valved conduit with a mechanical or bioprosthetic valve are acceptable alternatives, with choice guided by
surgeon training and experience
IIa B
Prosthetic valve IE
If there is annulus destruction and invasion outside the aortic root and root reconstruction and replacement is required, an allograft or a biologic tissue
root is preferable to a prosthetic valved conduit IIa B
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
McGiffin et al (1992) Aortic valve infection. Risk factors for death and recurrent endocarditis after aortic valve replacement. J Thorac Cardiovasc Surg 104:511-520
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Hussain et al (2017) Challenging allograft use for aortic valve infective endocarditis: Is it the allograft or the surgeon?
J Thorac Cardiovasc Surg 153:280-1
Hussain et al (2017) Allografts remain a cornerstone of surgical treatment of invasive and destructive aortic valve infective endocarditis: Surgeon and technique do matter!
J Thorac Cardiovasc Surg 154:1900-1
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Calcified homograft 10 years post-op
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Calcified homograft 12 years post-op
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Re-do aortic valve replacement after previous
homograft aortic root replacement
Retrospective study of the outcome of re-do aortic valve surgery in patients who had previously undergone homograft aortic root replacement The data were obtained from the Trust’s returns to NICOR (National Institute for Cardiovascular Research Outcomes) Long-term survival data cross-checked with the NHS Spine
Data are presented as mean ± standard error of the mean (μ±SEM)
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Demographics
Between 1998 & 2016 , 318 patients were eligible for inclusion in the analysis
Age 56±4.5 years
Sex ratio M:F = 231:87 (2.7:1 )
Freedom from re-intervention: 11.8 ± 0.94 yrs
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Operative urgency
Status Patients (n) %
Elective 242 76
Urgent 60 19
Emergency 16 5
20 patients (6%) were recorded as having active infective endocarditis at the time of surgery
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Previous sternotomies
No. of previous sternotomies
Patients (n) %
1 218 69
2 77 24
3 21 7
4 2
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Choice of aortic valve replacement
Procedure Patients (n) %
Mechanical AVR 108 34
Stented bioprosthesis 94 30
Homograft 64 20
Stentless bioprosthetic root 38 12
Pulmonary autograft 11 4
Rapid deployment bioprosthesis 2
Mechanical Bentall 1
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Cardiopulmonary bypass
μ SEM
Cross-clamp time (min) 114 2.7
Total CPB time (min) 168 4.9
3 patients required mechanical circulatory support with either Levitronix or ECMO
Concomitant procedures
79 patients underwent one or more concomitant procedures including CABG, MVR/MV rep, other aortic procedures
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Survival
30-day all cause/hospital mortality was 5.7% (18 patients)
Median duration of follow-up was 9.2 years
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Kaplan-Meier survival curve
Pro
bab
ility
Year 2 4 6 8 10 12 14 16 18
No at risk 267 250 218 208 144 118 73 50 19
Time (years)
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Actuarial survival
Years %
1 88
5 81
10 70
15 65
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Duncan et al (2015) Valve-in-valve transcatheter aortic valve implantation for failing surgical aortic stentless bioprosthetic valves: A single-center experience J Thorac Cardiovasc Surg 150:90-98
22 patients (17 homografts, 3 SPV, 1 Freestyle, 1 David)
TAVR with CoreValve
Device migration in 3 cases
No early deaths
14% mortality at one year
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
Conclusions
Redo AVR after homograft aortic root replacement can be a daunting operation but can be accomplished with good short- and long-term outcomes
A versatile operative strategy is required in order to deal with the calcified aortic root
Concern about the complexity of the subsequent redo operation should not preclude homograft use when otherwise indicated, particularly in endocarditis
TAVR has an increasing role in all redo AVR surgery
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
CB 52y m
• Congenital bicuspid valve
• Valvotomy in childhood
• Lost to follow-up and re-presented in 2016 with severe AS
• S. aureus grown in blood but patient well, with normal serum markers, afebrile with normal WCC
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
CB 52y m • 25 mm CE stented
bioprosthesis
• Uneventful surgery
• TOE in theatre showed no PVL
• Uneventful 1st 12 hours
• Overnight became profoundly vasoplegic and febrile
Imperial College of Science Technology and Medicine
Aortic Unit Royal Brompton & Harefield NHS Foundation Trust
CB 52y m • Emergency aortic root
replacement on Day 1 post-op
• Uneventful course thereafter
• On IV antibiotics for 6 weeks