Original Research Article

Study of surgical techniques associated with re- replacement of valve at a tertiary care hospital

Kishor Narayan Deore

Assistant Professor, Department Of Cardiovascular & Thoracis Surgery(CVTS), Rajarshi Chhatrapati Shahu Maharaj Government Medical College And CPR Hospital, Kolhapur, Maharashtra, INDIA. Email: [email protected]

Abstract Background: Patients earlier operated for heart valves may require redo surgery for endocarditis (commonest cause of re- operation, 60% for mechanical valves and 29% for bioprosthetic valves), structural deterioration in bioprosthetic valves (due to their limited durability), etc. Redo-Surgical has been the gold standard for the treatment of failing bio-prostheses. However it carries an inherent risk associated with a reoperative open heart surgery. Recent years have witnessed significant improvements in the clinical and functional outcomes of patients undergoing revision valvular surgery. In present study, we aimed to assess different surgical techniques for redo conducted at a single tertiary care hospital. Material and Methods: Present study was a prospective, observational and non-randomised study conducted in department of cardiovascular and thoracic surgery in patients requiring valve surgery in patients with a history of prior heart valve surgery. Results: During study period total 34 redo heart valve surgeries were conducted at our tertiary care hospital. Mean age of patients was 49.7 ± 11.6 years. Male to female ratio was 1.4:1. As per primary operation 47% had replacement , 24% had replacement, 18% and 12% had tricuspid valvuloplasty. Pre-operatively 9%, 62% and 29% patients had NYHA class II,III and IV symptoms respectively. 41 % patients had pre-operative atrial fibrillation. Mean Left ventricular ejection fraction was 43.1 ± 15.9 %. Elective (82%) surgeries were far common than urgent (18%) surgeries. Total 28 pre-operative patients had valve prosthesis, bioprosthetic (39%) were less than mechanical valves (61%).Pre-existing morbidity such as hypertension (56%), diabetes melitus (18%), chronic obstructive pulmonary disease (9%), chronic kidney disease (% eGFR < 60 mL/min/1.73 m2) (6%), congestive heart failure (6%) were noted in present study. Current smoking was present in 32% patients. Endocarditis (50%) was most common cause for redo surgery. Mean postoperative hospital stay was 13.5 ± 8.6 days. Supra-ventricular arrhythmias (26%) was most frequent complication. Other complications were heart failure (15%), reqiured haemodialysis (9%), required permanent pacemaker (9%), required haemofiltration (9%), low output syndrome (6%), arrhythmia (6%), sepsis (6%), cerebrovascular event (6%), re-exploration for bleeding (3%). 4 patients had mortality during hospitalisation, while 1 patient had mortality during follow-up. Total 15% mortality was noted in present study. Conclusion: Redo valve surgery patients have multiple pre-operative morbidities, intra-operative difficulties and a difficult post-operaive course. Routine pre-operative computed tomography scanning, minimally invasive approach during sternostomy, femoral vessel exposure before sternotomy, prophylactic and a right thoracotomy approach can ease intraoperative course. Key Words: redo valve surgery, AVR, mitral valve repair, ViV-TAVI.

*Address for Correspondence: Dr Kishor Narayan Deore, Assistant Professor, Department Of Cardiovascular And Thoracis Surgery(CVTS), Rajarshi Chhatrapati Shahu Maharaj Government Medical College And CPR Hospital, Kolhapur, Maharashtra, INDIA. Email: [email protected] Received Date: 20/11/2019 Revised Date: 19/12/2019 Accepted Date: 04/02/2020 DOI: https://doi.org/10.26611/1061437

Valvular heart disease is one of the common causes of Access this article online cardiac morbidity and mortality.1 The burden of VHD is Quick Response Code: growing worldwide due to the high incidence of rheumatic Website: heart disease, especially in developing countries and the

www.medpulse.in increase in degenerative etiologies in industrialised nations.2 Many of them required surgical corrections. Patients earlier operated for heart valves may require redo

Accessed Date: surgery for endocarditis (commonest cause of re-operation, INTRODUCTION 60% for mechanical valves and 29% for bioprosthetic 22 June 2020 valves), structural deterioration in bioprosthetic valves (due to their limited durability), etc.3 Redo-Surgical Valve

How to cite this article: Kishor Narayan Deore. Study of surgical techniques associated with re-replacement surgery of heart valve at a tertiary care hospital. MedPulse International Journal of Surgery. June 2020; 14(3): 61-66. https://www.medpulse.in/Surgery/ MedPulse International Journal of Surgery, Print ISSN: 2550-7591, Online ISSN: 2636-4751, Volume 14, Issue 3, June 2020 pp 61-66

Replacement has been the gold standard for the treatment Important details such as previous cardiac procedures such of failing bio-prostheses. However it carries an inherent as number of reinterventions on the valve; preoperative CT risk associated with a reoperative open heart surgery.4 scanning; instauration of CPB through peripheral vascular Recent years have witnessed significant improvements in access before sternotomy; major cardiovascular iatrogenic the clinical and functional outcomes of patients undergoing injury at re-entry, type of surgical intervention, type of revision valvular surgery.3 As the proportion of patients valve surgery at redo (i.e. repair or replacement); type of receiving biologic (AVR) implanted prosthesis (i.e. biological or mechanical), type increases over time, more and more patients are expected of mitral ring (if mitral repair was executed, i.e. complete, to require repeat aortic valve surgery (rAVS).5 The most incomplete, pericardial band), previous valve surgery; common indications for rAVS are bioprosthetic structural previous aortic surgery, route of (i.e. valve degeneration, prosthetic valve endocarditis, antegrade, retrograde, antegrade + retrograde, no paravalvular leak, and thrombosis or pannus formation in cardioplegia with fibrillating cooled unloaded heart); mechanical aortic valves.6 Upto 20% of patients administration of cardioplegia into previous patent vein undergoing primary mitral valve surgery require grafts; type of medium of cardioplegic solution (blood, reoperation on long-term follow-up. Factors such as valve intracellular crystalloid, extracellular crystalloid, cold degeneration, valve dehiscence, mitral repair failure, and fibrillating heart), aortic cross-clamping time, CPB time, endocarditis contribute to the need for reoperation in these etc were also noted. All pre, intra and post-operative details patients. Redo mitral surgery is associated with poor short were noted in pre-designed proforma. Important factors and long-term outcomes. With the growing popularity of such as operative mortality, re-exploration for bleeding, transcatheter valve replacement for severe aortic , low cardiac output syndrome (LCOS), need for there is new interest in using transcatheter mitral valve postoperative (since aortic declamping) intra-aortic replacement(TMVR) for redo mitral procedures.7,8 In balloon pumping (IABP); prolonged intubation, acute present study, we aimed to assess different surgical respiratory failure (ARF), pneumonia, stroke, acute renal techniques for redo heart valve surgeries conducted at a insufficiency (ARI), need of transfusions, massive intra- single tertiary care hospital. and/or postoperative (i.e. perioperative) transfusions, deep sternal wound infection, length in ICU and length of in- MATERIAL AND METHODS hospital stay were documented. Follow up was kept till 30 Present study was a prospective, observational and non- postoperative days. Collected data was entered in randomised study conducted in department of Microsoft excel sheet and analysed. Statistical analysis cardiovascular and thoracic surgery, XXX medical college was done using descriptive statistics. and hospital, XXX. Patients undergoing redo valve surgery from January 2018 to December 2019 were considered for RESULTS present study. Institutional Ethical Committee approval for During study period total 34 redo heart valve surgeries the study was taken. Individual patient consent was taken were conducted at our tertiary care hospital. Mean age of for participation in the study. patients was 49.7 ± 11.6 years. Male to female ratio was Inclusion criterion 1.4:1. As per primary operation 47% had mitral valve Any type of valve surgery performed in patients with a replacement , 24% had aortic valve replacement, 18% history of prior heart valve surgery. mitral valve repair and 12% had tricuspid valvuloplasty. The choice for a , re-repair or a Pre-operatively 9%, 62% and 29% patients had NYHA mechanical or biological prosthetic replacement, was class II,III and IV symptoms respectively. 41 % patients based on hospital policies and on patient preference. had pre-operative atrial fibrillation. Mean Left ventricular Anaesthesia, surgery, myocardial protection techniques as ejection fraction was 43.1 ± 15.9 %. Elective (82%) well as postoperative care were based on hospital’s surgeries were far common than urgent (18%) surgeries. standardized protocols. Intraoperative details were Total 28 pre-operative patients had valve prosthesis, collected from every patient’s intraoperative surgical bioprosthetic (39%) were less than mechanical valves report. All resternotomies were performed with the aid of (61%).Pre-existing morbidity such as hypertension (56%), an oscillating saw. The use of preoperative computed diabetes melitus (18%), chronic obstructive pulmonary tomography (CT) scan, institution of cardiopulmonary disease (9%), chronic kidney disease (% eGFR < 60 bypass (CPB) before resternotomy and use of thoracotomy mL/min/1.73 m2) (6%), congestive heart failure (6%) were approaches varied among experiences, and were analysed noted in present study. Current smoking was present in as variables potentially impacting operative mortality. 32% patients.

MedPulse International Journal of Surgery, Print ISSN: 2550-7591, Online ISSN: 2636-4751, Volume 14, Issue 3, June 2020 Page 62 Kishor Narayan Deore

Table 1: Patient’s preoperative clinical data Variable Mean ± SD or Number (n = 34) Percentage (%) Age (years) 49.7 ± 11.6 Gender Male 20 59% Female 14 41% Primary operation Mitral valve repair 6 18% 16 47% Aortic valve replacement 8 24% Tricuspid valvuloplasty 4 12% New York Heart Association class Class II 3 9% Class III 21 62% Class IV 10 29% Atrial fibrillation (n) 14 41% Left ventricular ejection fraction (%) 43.1 ± 15.9 Urgency Of surgery Elective 28 82% Urgent 6 18% Pre-existing morbidity Hypertension 19 56% Diabetes 6 18% Chronic Obstructive Pulmonary Disease 3 9% Chronic kidney disease 2 6% (% eGFR < 60 mL/min/1.73 m2) Congestive heart failure 2 6% current smoking 11 32% Types of prosthesis (n= 28) Bioprosthetic 11 39% Mechanical 17 61%

Endocarditis (50%) was most common cause for redo surgery. Other causes were para-prosthetic leak (15%), prosthetic dysfunction (9%), prosthetic valve thrombosis (15%) and other (12%). 26 % patients were posted for aortic valve surgery. Patients were posted for repair (3%), replacement (21%) and repair of in-situ prosthesis (3%). On investigations patients had stenosis (6%), regurgitation (15%) and mixed (6%) aortic valve disease. Prosthetic dysfunction (15%) was most common aortic valve pathology. Other pathologies were dissection (3%), calcified (6%) and rheumatic (3%). Mitral valve surgery was needed in 65% patients. Repair (9%), replacement (53%) and repair of in-situ prosthesis (3%) were needed. Regurgitation (47%) was most common Mitral Valve disease followed by stenosis (6%) and mixed (12%) lesions. Mitral Valve pathologies in present study were Prosthetic dysfunction (41%), Myxomatous (9%), Rheumatic (9%) and Other (6%). Tricuspid valve surgery was needed in 12% patients, repair of Tricuspid Valve was needed. All patients had Regurgitation Secondary to other pathologies. Aortic Valve Replacement (AVR) + Tricuspid Valve Repair (TVR) was done in 1 patient (3%). Concomitant CABG was done in total 10 patients (29%).

Table 2: Details of Recent valve Surgery and Valve Pathology Variable Number (n = 34) Percentage (%) Probable cause for Redo surgery Endocarditis 17 50% Para-prosthetic leak 5 15% Prosthetic dysfunction 3 9% Prosthetic valve thrombosis 5 15% Other 4 12% Aortic valve surgery Repair 1 3% Replacement 7 21% Repair of in-situ prosthesis 1 3%

MedPulse International Journal of Surgery, Print ISSN: 2550-7591, Online ISSN: 2636-4751, Volume 14, Issue 3, June 2020 pp 61-66

Aortic Valve disease Stenosis 2 6% Regurgitation 5 15% Mixed 2 6% Aortic Valve pathology Prosthetic dysfunction 5 15% Dissection 1 3% Calcified 2 6% Rheumatic 1 3% Mitral valve surgery Repair 3 9% Replacement 18 53% Repair of in-situ prosthesis 1 3% Mitral Valve disease Stenosis 2 6% Regurgitation 16 47% Mixed 4 12% Mitral Valve pathology Prosthetic dysfunction 14 41% Myxomatous 3 9% Rheumatic 3 9% Other 2 6% Tricuspid valve surgery Repair 4 12% Tricuspid Valve disease Regurgitation 4 12% Tricuspid Valve pathology Secondary 3 9% Aortic Valve Replacement (AVR) + Tricuspid Valve Repair (TVR) 1 3% Concomitant CABG 10 29% Operative characteristics of study group patients are described in table 3.

Table 3: Summary of Operative Variables Operative characteristic Mean ± SD or Number (n = 34) (%) Total surgery (min) 281 ± 112 Cardiopulmonary bypass (min) 147 ± 59 Cross-clamp (min) 81 ± 24 Blood loss during operation (ml) 203 ± 98 Blood transfusion during operation (ml) 290 ± 232 Incision length (cm) 13 ± 3.1 Concomitant procedures 11 (32%) Ventilator >24 hours was needed in 38% patients. 68 % patients required intensive care unit stay more than 3 days. Continuous renal replacement therapy in post-operative patients was required in 21% patients. Extracorporeal membrane oxygenation was required in 15% patients. Mean postoperative hospital stay was 13.5 ± 8.6 days. Supra-ventricular arrhythmias (26%) was most frequent complication. Other complications were heart failure (15%), reqiured haemodialysis (9%), required permanent pacemaker (9%), required haemofiltration (9%), low output syndrome (6%), arrhythmia (6%), sepsis (6%), cerebrovascular event (6%), re-exploration for bleeding (3%). 4 patients had mortality during hospitalisation, while 1 patient had mortality during follow-up. Total 15% mortality was noted in present study.

Table 4: Postoperative characteristics Characteristics Mean ± SD or Number (n = 34) Percentage (%) Ventilator >24 h (n) 13 38% Intensive care unit stay >3 day (n) 23 68% Continuous renal replacement therapy (n) 7 21% Extracorporeal membrane oxygenation (n) 5 15% Postoperative hospital stay (days) 13.5 ± 8.6 Mortality (%) 4 12%

MedPulse International Journal of Surgery, Print ISSN: 2550-7591, Online ISSN: 2636-4751, Volume 14, Issue 3, June 2020 Page 64 Kishor Narayan Deore

Complications (%) 0% Supra-ventricular arrhythmias 9 26% Heart failure 5 15% Newly haemodialysis 3 9% Permanent pacemaker 3 9% Haemofiltration 3 9% Low output syndrome (n) 2 6% Arrhythmia 2 6% Sepsis 2 6% Cerebrovascular event 2 6% Re-exploration for bleeding 1 3% Mortality During follow-up (%) 1 3% Total mortality (%) 5 15%

DISCUSSION dysfunction, urgent or emergent priority, increased NYHA The nonregenerative valve replacements (e.g., mechanical, class and pulmonary hypertension. Similar findings were bioprosthetic, and nondegradable polymeric valves) have noted in present study.9,11 Total 15% mortality was noted been developed to ensure long term functionality upon in present study. The results of redo AVR have been implantation without possibility of integration, studied by many authors. In older series, the mortality was remodelling, or growth. Due to this major drawback, in relatively high, reaching as high as 10%-15%.15 In more particular young patients have to undergo multiple modern series, this mortality has dropped to more surgeries and edo interventions to replace the valve reasonable levels and has been reported to be between 3% substitute over their lifetime, with an increasing risk of and 6%.16,17 At some centers, mortality at second operation morbidity and mortality. Mitral valve surgery after prior approaches that of primary operation.17 The likely causes is considered as a demanding procedure for this decrease in mortality are improvements in with higher risks of adverse events than first-time surgery. preoperative imaging, better myocardial protection, and Although a number of institutional series have reported a improved perioperative management of this complex reduction in operative mortality in ReMVS during the last patient group. Finally, advances in perioperative years, a recent study still reported a 12% hospital mortality management in the last few decades have reduced in these patients.9 Reoperative cardiac valve surgery mortality in increasingly complex cardiac operations and through a continues to be a common reoperations. Higher mortality in present study was due to surgical approach but is technically challenging. It has old age, multiple co-morbdities, pre-operative heart several associated risks including injury to the right failure, etc. , injury to patent coronary artery bypass grafts and In the current era transcatheter aortic valve implantation bleeding, thereby increasing operative morbidity and (TAVI) is becoming an increasingly viable option mortality. In the setting of reoperative cardiac surgery, the particularly for the higher risk redo operations. Any redo sternotomy had been proven to be one of the most discussion of redo AVR in the current era requires dangerous phases of the operation, particularly for patients consideration of transcatheter AVR(TAVR). With the with huge heart or firm and gapless adhesion.10,11 Most advent of TAVR, many patients will move from redo open reports refer that the quality of repair or replacement, as surgery to the less invasive transcatheter approach, well as the safety of the procedure are not affected by a especially those with high operative risk. The 5-year minimally invasive approach when compared with results of the Placement of AoRtic TraNscathetER Valves sternotomy,12 We also used minimally invasive approach (PARTNER) trial demonstrated equivalent outcome in whenever possible. Other protective strategies described high-risk patients.18 for safe redo cardiac valve surgical procedures, including Valve-in-Valve transcatheter aortic valve implantation femoral vessel exposure before sternotomy, prophylactic (ViV-TAVI) is also a novel alternative approach to redo- initiation of cardiopulmonary bypass, and a right SAVR, with Medtronic and Edwards valves receiving thoracotomy approach. Similar measures were taken in our FDA approval in 2015 and 2017, respectively. A host of institute.13,14 We preferers routine computed tomography retrospective studies have shown the feasibility of ViV- scanning visualize the relationship of the mediastinal TAVI, however there are no randomized controlled trials contents to the sternum and to identify the patients at risk comparing it with redo-SAVR.19,20 Same as minimally for injury during re-entry. Previous studies have identified invasive aortic surgery tries to compete with transcatheter preoperative risk factors affecting early and late mortality, aortic valve implantation (TAVI), minimally invasive such as advanced age at surgery, left ventricular mitral valve surgery is in better conditions to compete

MedPulse International Journal of Surgery, Print ISSN: 2550-7591, Online ISSN: 2636-4751, Volume 14, Issue 3, June 2020 pp 61-66 against transcatheter mitral valve repair (TMVR), as outcome with mechanical versus biologic prostheses. J percutaneous repair of degenerative disease is very inferior Thorac Cardiovasc Surg 2008;135:878–84. to the Mohr type technique by minimally invasive cardiac 6. Potter DD, Sundt TM 3rd, Zehr KJ, et al.. Operative risk of reoperative aortic valve replacement. J Thorac surgery (MICS). Cardiovasc Surg 2005;129:94 –103. 7. Bourguignon T, Bouquiaux- Stablo AL, Loardi C,etal. CONCLUSION Very late outcomes for mitral valve replacement with the Redo valve surgery patients have multiple pre-operative Carpentier-Edwards pericardial bioprosthesis:25-year morbidities, intra-operative difficulties and a difficult post- follow-up of 450 implantations. J Thorac Cardiovasc Surg 2014;148:2004–11 e1. operaive course. Routine pre-operative computed 8. Kwedar K, McNeely C, Zajarias A, etal. Outcomes of tomography scanning, minimally invasive approach during early mitral valve reoperation in the Medicare population. sternostomy, femoral vessel exposure before sternotomy, Ann Thorac Surg 2017;104:1516–21. prophylactic cardiopulmonary bypass and a right 9. Vohra HA, Whistance RN, Roubelakis A, Burton A, thoracotomy approach can ease intraoperative course. Barlow CW, Tsang GMK et al.. Outcome after redo-mitral Recent advances such as Valve-in-Valve transcatheter valve replacement in adult patients: a 10-year single-centre experience. Interact Cardiovasc Thorac Surg 2012; aortic valve implantation (ViV-TAVI), transcatheter mitral 14:575–9. valve repair (TMVR) have bright future in redo valve 10. Park CB, Suri RM, Burkhart HM, Greason KL, Dearani surgery. JA, Schaff HV, et al.. Identifying patients at particular risk of injury during repeat sternotomy: analysis of 2555 cardiac reoperations. J Thorac Cardiovasc Surg. 2010; REFERENCES 140:1028–35. 1. Baskett RJ, Exner DV, Hirsch GM, et al.. Mitral 11. Ghoreishi M, Dawood M, Hobbs G, Pasrija C, Riley P, insufficiency and morbidity and mortality in left Petrose L, et al.. Repeat sternotomy: no longer a risk factor ventricular dysfunction. Can J Cardiol 2007; 23:797-800. in mitral valve surgical procedures. Ann Thorac Surg. 2. Iung B, Vahanian A. Epidemiology of acquired valvular 2013;96:1358–65. heart disease. Can J Cardiol 2014; 30:962-70. 12. Botta L, Cannata A, Bruschi G, Fratto P, Taglieri C, Russo 3. Jamieson WR, Burr LH, Miyagishima RT, Janusz MT, CF, et al.. Minimally invasive approach for redo mitral Fradet GJ, Lichtenstein SV et al.. Reoperation for valve surgery. J Thorac Dis. 2013;5 Suppl 6:S686-93. bioprosthetic mitral structural failure: risk assessment. 13. Arcidi JM Jr, Rodriguez E, Elbeery JR, Nifong LW, Efird Circulation 2003;108:98–102. JT, Chitwood WR Jr. Fifteen-year experience with 4. Chan V, Malas T, Lapierre H, et al.. Reoperation of left minimally invasive approach for reoperations involving heart valve bioprostheses according to age at implantation. the mitral valve. J Thorac Cardiovasc Surg. Circulation. 2011;124: S75–S80. 2012;143:1062–8. 5. Brown ML, Schaff HV, Lahr BD, et al.. Aortic valve replacement in patients aged 50 to 70 years: improved Source of Support: None Declared Conflict of Interest: None Declared

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