Parsimonious assessment for reoperative aortic valve replacement; the deterrent effect of low left ventricular ejection fraction and renal impairment

Abstract

Background: Patient comorbidities play a pivotal role in the surgical outcomes of reoperative aortic valve replacement (re-AVR). Low left ventricular ejection fraction (LVEF) and renal insufficiency (Cr >2 mg/dL) are known independent surgical risk factors. Improved preoperative risk assessment can help determine the best therapeutic approach. We hypothesize that re-AVR patients with low LVEF and concomitant renal insufficiency have a prohibitive surgical risk and may benefit from transcatheter AVR (TAVR).Methods: From January 2002 to March 2013, we reviewed 232 patients who underwent isolated re-AVR.Patients older than 80 years were excluded to adjust for unobserved frailty. We identified 37 patients with a ≤35% LVEF (low ejection fraction group-LEF) and 195 patients with >35% LVEF (High ejection fraction group-HEF).Results: The mean age was 68.4±11.5 years and there were more females (86.5% versus 64.1%, P=0.007) in the LEF group. The prevalence of renal insufficiency was higher in LEF patients (27% versus 5.6%, P=0.001).Higher operative mortality (13.5% versus 3.1%, P=0.018) was observed in the LEF group. Stroke rates were similar in both groups (8.1% versus 4.1%, P=0.39). Unadjusted cumulative survival was significantly lower in LEF patients (6.6 years, 95% CI: 5.2-8.0, versus 9.7 years, 95% CI: 8.9-10.4, P=0.024). In patients without renal insufficiency, LEF and HEF had similar survival (8.3 years, 95% CI: 7.1-9.5, versus 9.9 years, 95% CI:9.1-10.6, P=0.90). Contrarily, in patients with renal insufficiency, LEF led to a significantly lower survival (1.1 years, 95% CI: 0.1-2.0, versus 4.8 years, 95% CI: 2.2-7.3, P=0.050). Adjusted survival analysis revealed elevations in baseline creatinine (HR =4.28, P<0.001) and LEF (HR =5.33, P=0.041) as significant predictors of long-term survival, with a significant interaction between these comorbidities (HR =7.28, P<0.001). Conclusions:In re-AVR patients, low LVEF (≤35%) is associated with increased operative mortality.Concomitant renal insufficiency in these patients results in a prohibitively low cumulative survival. These reoperative surgical outcomes should warrant expanding the role of TAVR for reoperative patients with LEF and renal impairment.

A retrospective study: do patients with left ventricular ejection fraction ≤50% benefit from heart valve surgery?

“…Typically, LVEF ≤40% was previously considered a contraindication for heart valve surgery; however, with recent improvements in anesthesia and extracorporeal circulation techniques, as well as improved postoperative monitoring, more and more cardiac centers have relaxed the contraindications, allowing more patients with severe valvular disease and low LVEF to be effectively treated. Yammine et al ( 6 ) found that in patients undergoing repeat aortic valve replacement (AVR), low LVEF (≤35%) was associated with increased operative mortality compared with LVEF >35% and the presence of renal insufficiency, resulting in very low cumulative survival. Macedo et al ( 7 ) found that in patients with poor LVEF, the results of heart valve beating replacement surgery were similar to those using conventional heart surgery.…”