title: Mid-term results of aortic valve surgery in redo scenarios in the current practice: results from the multicentre European RECORD (REdo Cardiac Operation Research Database) initiative†.
abstract: OBJECTIVE
  Although commonly reported as single-centre experiences, redo aortic valve replacement (RAVR) has overall acceptable results. Nevertheless, trans-catheter aortic valve replacement has recently questioned the efficacy of RAVR.
  
  
  METHODS
  Early-to-mid-term results and determinants of mortality in 711 cases of RAVR from seven European institutions were assessed in the entire population and in selected high-risk subgroups [elderly >75 years, urgent/emergent procedures, preoperative New York Heart Association (NYHA) functional Class IV and endocarditis].
  
  
  RESULTS
  Hospital mortality was 5.1%, major re-entry cardiovascular complications (MRCVCs) 4.9%, low cardiac output syndrome (LCOS) 15.3%, stroke 6.6%, acute respiratory failure (ARF) 10.6%, acute renal insufficiency (ARI) 19.3% and need for continuous renal replacement therapy (CRRT) 7.2%, transfusions 66.9% and for permanent pacemaker (PMK) 12.7%. Mid-term survival, freedom from acute heart failure (AHF), reinterventions, stroke and thrombo-embolisms were 77.2 ± 2.7, 84.4 ± 2.6, 97.2 ± 0.8, 97.2 ± 0.9 and 96.3 ± 1.2%, respectively; 87.5% of patients were in NYHA functional Class I-II. Preoperative left ventricular ejection fraction of <30% [odds ratio (OR) 8.7, 95% confidence interval (CI) 2.1-35.6], MRCVCs (OR 20.9, 95% CI 5.6-78.3), cardiopulmonary bypass time (OR 1.1, 95% CI 1.0-1.1), perioperative LCOS (OR 17.2, 95% CI 5.1-57.4) and ARI (OR 5.1, 95% CI 1.5-18.1) predicted hospital death. Endocarditis (OR 7.5, 95% CI 2.9-19.1), preoperative NYHA functional Class IV (OR 4.7, 95% CI 1.0-24.0), combined RAVR + mitral surgery (OR 5.1, 95% CI 1.5-17.3) and AHF at follow-up (OR 2.8, 95% CI 1.3-6.0) predicted late death at the Cox proportional hazard regression model. Elderly >75 years had similar hospital mortality (P = 0.06) and major morbidity, except for a higher need for PMK (P = 0.03), as well as comparable mid-term survival (P = 0.89), freedom from AHF (P = 0.81), reinterventions (P = 0.63), stroke (P = 0.21) and thrombo-embolisms (P = 0.09). Urgent/emergent indication resulted in higher hospital death, LCOS, transfusions, MRCVCs, intra-aortic balloon pumping (IABP), stroke, prolonged (>48 h) ventilation, pneumonia, ARI, CRRT, lower mid-term survival and freedom from AHF (P ≤ 0.03). Preoperative NYHA functional Class IV correlated with higher LCOS, IABP, prolonged ventilation, pneumonia, ARF, ARI, CRRT and MRCVCs and lower mid-term survival, freedom from AHF, reinterventions and stroke (P ≤ 0.02). Endocarditis demonstrated higher hospital mortality, MRCVCs, LCOS, IABP, stroke, ARF, prolonged intubation, pneumonia, ARI, CRRT, transfusions and PMK and lower mid-term survival and freedom from AHF and reinterventions (P ≤ 0.04).
  
  
  CONCLUSIONS
  RAVR achieves overall satisfactory results. Baseline risk factors and perioperative complications strongly affect outcomes and mandate improvements in perioperative management. New emerging strategies might be considered in selected high-risk cases.
authors.affiliation: Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy frankono@libero.it.
authors.forename: Francesco
authors.initials: F
authors.lastname: Onorati
authors.affiliation: Division of Cardiac Surgery, University of Oulu, Oulu, Finland.
authors.forename: Fausto
authors.initials: F
authors.lastname: Biancari
authors.affiliation: Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Naples, Italy.
authors.forename: Marisa
authors.initials: M
authors.lastname: De Feo
authors.affiliation: Cardiac Surgery Unit, Varese University Hospital, Varese, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Mariscalco
authors.affiliation: Cardiac Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Messina
authors.affiliation: Department of Cardiac Surgery, Klinikum Nürnberg, Nuremberg, Germany.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Santarpino
authors.affiliation: Division of Cardiac Surgery, IRCCS San Martino University Hospital, Genoa, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Santini
authors.affiliation: Cardiac Surgery Unit, Varese University Hospital, Varese, Italy.
authors.forename: Cesare
authors.initials: C
authors.lastname: Beghi
authors.affiliation: Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Naples, Italy.
authors.forename: Giannantonio
authors.initials: G
authors.lastname: Nappi
authors.affiliation: Cardiac Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Troise
authors.affiliation: Department of Cardiac Surgery, Klinikum Nürnberg, Nuremberg, Germany.
authors.forename: Theodor
authors.initials: T
authors.lastname: Fischlein
authors.affiliation: Division of Cardiac Surgery, IRCCS San Martino University Hospital, Genoa, Italy.
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Passerone
authors.affiliation: Division of Cardiac Surgery, University of Oulu, Oulu, Finland.
authors.forename: Juni
authors.initials: J
authors.lastname: Heikkinen
authors.affiliation: Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Faggian
mesh_terms: D000328:Adult; D000368:Aged; D001021:Aortic Valve / Q000601:surgery*; D004697:Endocarditis, Bacterial / Q000601:surgery; D005060:Europe; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods / Q000401:mortality* / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000601:surgery; D012086:Reoperation / Q000379:methods / Q000401:mortality* / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D055815:Young Adult
keywords: Aortic valve replacement; Emergent cardiac surgery; Endocarditis; Prosthetic endocarditis; Redo