title: Reoperative aortic valve replacement in the octogenarians-minimally invasive technique in the era of transcatheter valve replacement.
abstract: OBJECTIVE
  Reoperative aortic valve replacement (re-AVR) in octogenarians is considered high risk and therefore might be indicated for transcatheter AVR. The minimally invasive technique for re-AVR limits dissection and might benefit this patient population. We report the outcomes of re-AVR in high-risk octogenarians who might be considered candidates for transcatheter AVR to assess the safety of re-AVR and minimally invasive operative techniques.
  
  
  METHODS
  We identified 105 patients, aged ≥80 years, who underwent open re-AVR at our institution from July 1997 to December 2011. Patients requiring concomitant coronary bypass surgery and/or other valve surgery were excluded. The outcomes of interest included operative mortality, postoperative complications, and midterm postoperative survival.
  
  
  RESULTS
  Of the 105 patients, 51 underwent minimally re-AVR through upper hemisternotomy (Mre-AVR) and 54 standard full sternotomy (Fre-AVR). The mean patient age was 82.8 ± 3.8 years. No significant differences were found in the patient risk factors. Postoperatively, 6 patients (5.7%) underwent reoperation for bleeding, 4 (3.8%) experienced permanent stroke, 4 (3.8%) developed new renal failure, and 22 (21.0%) had new-onset atrial fibrillation. Overall, the operative mortality was 6.7%, and the 1- and 5-year survival was 87% and 53%, respectively. When Mre-AVR and Fre-AVR were compared, the operative mortality was 9.2% in the Fre-AVR group and 3.9% in the Mre-AVR group (P = .438). Kaplan-Meier analysis showed a survival benefit at both 1 year (79% ± 11.7% vs 92% ± 7.8%) and 5 years (38% ± 17.6% vs 65% ± 15.7%, P = .028) favoring Mre-AVR. Cox regression analysis identified heparin-induced thrombocytopenia, reoperation for bleeding, older age, full sternotomy, and an infectious complication as predictors of mortality.
  
  
  CONCLUSIONS
  Octogenarians who undergo re-AVR are thought to be high-risk surgical candidates. The present single-center series revealed acceptable in-hospital outcomes and operative mortality. Mre-AVR was associated with better survival compared with Fre-AVR and might benefit this population.
authors.affiliation: Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass.
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Kaneko
authors.affiliation: Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass.
authors.forename: Dan
authors.initials: D
authors.lastname: Loberman
authors.affiliation: Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass.
authors.forename: Igor
authors.initials: I
authors.lastname: Gosev
authors.affiliation: Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass.
authors.forename: Fadi
authors.initials: F
authors.lastname: Rassam
authors.affiliation: Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass.
authors.forename: Siobhan
authors.initials: S
authors.lastname: McGurk
authors.affiliation: Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass.
authors.forename: Marzia
authors.initials: M
authors.lastname: Leacche
authors.affiliation: Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass. Electronic address: lcohn@partners.org.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Cohn
mesh_terms: D000367:Age Factors; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D020878:Device Removal; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D006351:Heart Valves; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D015999:Multivariate Analysis; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D012086:Reoperation; D012307:Risk Factors; D056346:Sternotomy / Q000379:methods*; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome
keywords: 28; 35.2; CI; Fre-AVR; HIT; HR; LITA; LV; Mre-AVR; STS; TAVR; TEE; The Society of Thoracic Surgeons; VIV; confidence interval; hazard ratio; heparin-induced thrombocytopenia; left internal thoracic artery; left ventricular; minimally invasive reoperative aortic valve replacement; re-AVR; reoperative aortic valve replacement; standard full sternotomy reoperative aortic valve replacement; transcatheter aortic valve replacement; transesophageal echocardiography; valve-in-valve