title: Re-do aortic valve replacement: does a previous homograft influence the operative outcome?
abstract: OBJECTIVE
  Late reoperation for failed aortic homograft is widely regarded as a high-risk procedure. A review is presented of the authors' experience of redo-aortic valve replacement (re-do AVR) examining factors which affect, and whether a previous aortic homograft replacement influences, operative outcome.
  
  
  METHODS
  A retrospective review was conducted of consecutive re-do AVR performed at the authors' institution between 1998 and 2002.
  
  
  RESULTS
  During the study period, 178 patients (125 males, 53 females; mean age 52.4 years; range: 16-85 years) underwent re-do AVR. The group included first-time (72%), second-time (20%), and more than third-time re-do AVR (8%). Forty-six patients (26%) received a homograft (group I), and 132 (74%) a stented biological/mechanical valve (group II). The two groups were matched for baseline clinical characteristics and operative variables. The type of explanted valve, and preoperative and operative variables, were analyzed using univariate and multivariate models. Primary outcome was defined as 30-day mortality, and secondary outcome as postoperative complications. The overall 30-day mortality was 12.3%, but was much lower (4.5%) for elective isolated and multiple re-do AVR. Univariate analysis showed significant predictors of 30-day mortality to be: age >65 years (p = 0.02); renal dysfunction (p = 0.005); preoperative unstable status (p = 0.03); preoperative NYHA class III/IV dyspnea (p = 0.02); non-elective operation (p = 0.01); preoperative arrhythmia (p = 0.005); history of chronic obstructive pulmonary disease (COPD) (p = 0.002); preoperative cardiogenic shock (p = 0.03); impaired left ventricular ejection fraction (LVEF) <50% (p = 0.04); and other valvular procedure(s) performed simultaneously (p = 0.01). In a multivariate analysis, the only significant predictors of 30-day mortality were impaired LVEF (p = 0.03) and a history of COPD (p = 0.007). Group I patients had a significantly shorter mean hospital stay (10.2+/-5.9 versus 14.1+/-12.5 days; p = 0.009), but there were no significant differences between groups in terms of postoperative complications.
  
  
  CONCLUSIONS
  A previous aortic homograft replacement was not associated with an increased operative risk at the time of re-do AVR. A history was COPD was an important predictor of 30-day mortality, and this finding requires further investigation.
authors.affiliation: Department of Cardiac Surgery, Royal Brompton Hospital, London, UK. pankajkumar66@hotmail.com
authors.forename: Pankaj
authors.initials: P
authors.lastname: Kumar
authors.forename: Thanos
authors.initials: T
authors.lastname: Athanasiou
authors.forename: Ayyaz
authors.initials: A
authors.lastname: Ali
authors.forename: Sujit
authors.initials: S
authors.lastname: Nair
authors.forename: Bilgehan S
authors.initials: BS
authors.lastname: Oz
authors.forename: Anthony
authors.initials: A
authors.lastname: DeSouza
authors.forename: Neil
authors.initials: N
authors.lastname: Moat
authors.forename: Darryl F
authors.initials: DF
authors.lastname: Shore
authors.forename: John R
authors.initials: JR
authors.lastname: Pepper
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001705:Bioprosthesis; D005260:Female; D006349:Heart Valve Diseases / Q000503:physiopathology / Q000601:surgery*; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D011475:Prosthesis Failure; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013318:Stroke Volume / Q000502:physiology; D016019:Survival Analysis; D014184:Transplantation, Homologous; D016896:Treatment Outcome