Transapical aortic valve implantation after previous heart surgery

Abstract

Transcatheter aortic valve implantation is a new method for the treatment of very-high-risk patients with aortic valve stenosis. Particularly in patients who have had previous cardiac surgery, the operative risk can be reduced. Nevertheless, this new procedure has some potential risks in these patients, due to the increased danger of endocarditis and in view of potential graft damage after previous bypass grafting or prosthesis damage after previous valve replacement, caused by wire manipulation or valve liberation. Between April 2008 and January 2010, 198 consecutive patients underwent transapical aortic valve implantation. Group A consisted of 158 patients without previous heart surgery and group B had 40 patients with previous heart operation (23 coronary artery bypass grafting, three aortic valve replacements, two mitral valve repairs, one replacement, and 11 combined operations). Although patients in group B (75 ± 11) were significantly younger than the ones in group A (80 ± 8) (p = 0.003), the preoperative risk score was significantly higher in group B (group A - the European System for Cardiac Operative Risk Evaluation (EuroSCORE): 37 ± 18%; the Society of Thoracic Surgeons (STS) mortality score: 21 ± 16; group B - EuroSCORE: 53 ± 21%; STS mortality score: 29 ± 18) (p < 0.001, p = 0.006). The technical success rate was 99.5% (157/158) in group A and 100% (40/40) in group B. One patient in group A developed an annulus rupture. The postoperative echocardiographic examinations showed low transvalvular gradient due to the special design of the valve, without differences between the two groups. The 30-day mortality was 6.9% in group A and 5.0% in group B, and the 1-year survival was 77% and 74% in group A and group B, respectively (nonsignificant). Transcatheter valve implantation can be performed successfully after previous heart surgery. Particular care should be taken to achieve optimal valve position and not to damage grafts or prosthetic valves during manipulation with guide wires or valve positioning.