The Risks and Benefits of Reoperation Aortic Valve Replacement

1. The Risks and Benefits of Reoperation Aortic Valve Replacement Vincent Gaudiani, MD Gary Grunkemeier, PhD Luis Castro, MD Audrey Fisher, MPH YingXing Wu, MD

2. Objectives • Compare the surgical risks of first time AVR vs. re-operative AVR in 1213 consecutive unselected patients. • Determine the risk factors that predict mortality in this series. • Assess the clinical risk of reoperation AVR compared to long term anticoagulation. The Risks and Benefits of Reoperation Aortic Valve Replacement

3. Risk of Anticoagulation Related Hemorrhage • The composite linearized rate of anticoagulation related hemorrhage in several large series averages 0.9 – 2.5% per year. Akins, Ann Thor Surg 61:806, 1996 The Risks and Benefits of Reoperation Aortic Valve Replacement

4. Patient Demographics The Risks and Benefits of Reoperation Aortic Valve Replacement

5. Age Histogram: First Operation vs. Reoperation * First Op Age Avg = 71 Reop Avg Age = 69 * Statistically significant at p<.05 The Risks and Benefits of Reoperation Aortic Valve Replacement

6. Prostheses Types First Operation (n=887) Reoperation (n=326) The Risks and Benefits of Reoperation Aortic Valve Replacement

7. Prior Cardiac Operations in Reoperative AVR’s (n=326) The Risks and Benefits of Reoperation Aortic Valve Replacement

8. Cardiac Findings The Risks and Benefits of Reoperation Aortic Valve Replacement

9. Coronary Disease The Risks and Benefits of Reoperation Aortic Valve Replacement

10. Concomitant Procedures The Risks and Benefits of Reoperation Aortic Valve Replacement

11. Operative Status The Risks and Benefits of Reoperation Aortic Valve Replacement

12. Operative Times The Risks and Benefits of Reoperation Aortic Valve Replacement

13. Operative Results The Risks and Benefits of Reoperation Aortic Valve Replacement

14. Factors Predicting Mortality by Multivariate Logistic Regression (p<0.10) • Factorp-valueOdds Ratio • Preop Dialysis 0.004 6.61 • Preop Cardiogenic Shock 0.001 4.94 • NYHA Class IV 0.070 1.93 • Female 0.071 1.85 • Perfusion Time 0.005 1.11 • Age 0.023 1.04 The Risks and Benefits of Reoperation Aortic Valve Replacement

15. Mortality by Age Group The Risks and Benefits of Reoperation Aortic Valve Replacement

16. Mortality by Age Group The Risks and Benefits of Reoperation Aortic Valve Replacement

17. Conclusions • The risks of re-operative AVR are low • The risks of long-term anticoagulation are known • We encourage all adult patients to choose the risks and benefits of tissue vs. mechanical AVR based upon a thorough discussion of these risks The Risks and Benefits of Reoperation Aortic Valve Replacement

18. Prosthesis Selection “ The choice of one type of valve versus the other is largely based on the surgeons’ or cardiologists’ views on what is the least harmful for the patient-anticoagulation for life, or the risk of reoperation.” Tirone E. David, M.D. Toronto General Hospital The Risks and Benefits of Reoperation Aortic Valve Replacement

19. Patient Demographics The Risks and Benefits of Reoperation Aortic Valve Replacement

20. Cardiac Findings The Risks and Benefits of Reoperation Aortic Valve Replacement

21. Coronary Disease The Risks and Benefits of Reoperation Aortic Valve Replacement

22. Prior Cardiac Operations The Risks and Benefits of Reoperation Aortic Valve Replacement

23. Concomitant Procedures The Risks and Benefits of Reoperation Aortic Valve Replacement

24. Operative Status The Risks and Benefits of Reoperation Aortic Valve Replacement

25. Operative Times The Risks and Benefits of Reoperation Aortic Valve Replacement

26. Operative Results The Risks and Benefits of Reoperation Aortic Valve Replacement