title: Aortic valve replacement after previous heart surgery in high-risk patients: transapical aortic valve implantation versus conventional aortic valve replacement-a risk-adjusted and propensity score-based analysis.
abstract: OBJECTIVE
  Cardiac reoperations have been associated with increased morbidity and mortality compared with first-time surgery. We analyzed our experience with reoperative aortic valve replacement (redo-AVR) and compared these results with those from patients who had undergone transapical aortic valve implantation (TA-AVI) as a second heart operation.
  
  
  METHODS
  In the present retrospective observational comparative study, we analyzed the outcome of 136 patients with previous cardiac surgery who had undergone conventional redo-AVR (n = 59; since 2006) or TA-AVI (n = 77; since 2008) with respect to the 30-day outcomes (Valve Academic Research Consortium criteria), 1- and 3-year survival, and the risk factors for both approaches after previous heart surgery.
  
  
  RESULTS
  Neither group differed significantly in their risk profile, leading to similar Society of Thoracic Surgeon score and EuroSCORE. The 30-day mortality was 3.39% (n = 2) in the redo-AVR group and 7.8% (n = 6) in the redo TA-AVI group (P = .465). The overall combined safety endpoint at 30 days was significantly lower for the TA-AVI patients (18.1% vs 33.9% in redo-AVR; P = .036). The unadjusted and adjusted 1-year survival showed no difference between the 2 groups. The unadjusted 3-year survival revealed a 2.1-fold greater mortality risk after TA-AVI (P = .055). Adjustment by multivariate Cox regression analysis (hazard ratio, 1.427; 95% confidence interval, 0.635-3.209; P = .389) and propensity score (hazard ratio, 1.571; 95% confidence interval, 0.575-4.291; P = .378) led to a >50% risk reduction, resulting in similar 3-year survival in the 2 groups.
  
  
  CONCLUSIONS
  Redo-AVR can be performed with acceptable results in high-risk patients and still serves as the reference standard. Reoperative valve surgery by TA-AVI is feasible and results in comparable short- and mid-term survival.
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany. Electronic address: maximilian.scherner@uk-koeln.de.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Scherner
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Navid
authors.initials: N
authors.lastname: Madershahian
authors.affiliation: Institute of Medical Statistics, Informatics and Epidemiology, University Hospital of Cologne, Cologne, Germany.
authors.forename: Kathrin
authors.initials: K
authors.lastname: Kuhr
authors.affiliation: Department of Cardiology, University Hospital of Cologne, Cologne, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Rosenkranz
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Stöger
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Parwis
authors.initials: P
authors.lastname: Rahmanian
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: YeongHoon
authors.initials: Y
authors.lastname: Choi
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Ingo
authors.initials: I
authors.lastname: Slottosch
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Jens
authors.initials: J
authors.lastname: Wippermann
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital Bochum, Bochum, Germany.
authors.forename: Justus
authors.initials: J
authors.lastname: Strauch
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Thorsten
authors.initials: T
authors.lastname: Wahlers
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000401:mortality; D005240:Feasibility Studies; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D057216:Propensity Score; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome