Repeat sternotomy for aortic valve replacement safe option for octogenarian patients

March 26, 2014, American Association for Thoracic Surgery

Surgical aortic valve replacement generally improves patients' symptoms and prolongs survival. However, the perceived risk of surgical aortic valve replacement in patients over 80 may result in surgery being denied or a recommendation for alternative therapy. Investigators at the Mayo Clinic challenge the way these patients have been managed. They report that repeat sternotomy in patients over 80 who have previously had coronary bypass graft surgery can be done with low risk. Their findings are published in the Journal of Thoracic and Cardiovascular Surgery, an official publication of the American Association for Thoracic Surgery.

"Our experience is that the prevalence of operative morbidity and mortality is the same as for primary sternotomy and surgical replacement," says lead investigator Kevin L. Greason, MD, Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN. "Based on the available evidence, there is no compelling argument to abandon the technique in favor of transcatheter replacement. Repeat sternotomy for surgical aortic valve replacement is a safe option."

The outcome of non-surgical management in elderly with symptomatic severe is disappointing. A prior study demonstrated that nearly half of patients in their 80s who were treated with aggressive medical therapy died within a year. There is general agreement that such patients benefit from surgical aortic valve replacement. Earlier studies have shown that this appears to be as safe as transcatheter replacement and that there was no difference in 30-day operative mortality rates in patients who received transcatheter replacement versus surgical replacement. But little is known about the potential risks of surgery.

To assess these risks, investigators reviewed the records of 629 octogenarian patients who had narrowing of the aortic valve in the heart and who had undergone sternotomy between January 1993 and December 2011. Of these, 111 patients (17.6%) had received a previous coronary artery bypass graft and therefore a repeat sternotomy was required. All patients had their surgery at the Mayo Clinic.

Those patients who underwent a repeat sternotomy had more pre-existing conditions and a higher predicted risk of death than those undergoing primary sternotomy. Despite the higher risk, the results in the repeat sternotomy group were similar to those in patients who received primary sternotomy. The cardiopulmonary bypass time was longer in the repeat sternotomy group compared with the primary sternotomy group, but there was no difference in the aortic crossclamp time between the two groups. Stroke occurred in three patients (2.7%) after repeat sternotomy and in 10 patients (1.9%) after primary sternotomy. Rates of myocardial infarction, renal failure, and reoperation for bleeding were similar between the two groups. Seven patients (6.4%) died after repeat sternotomy and 19 patients (3.7%) died after primary sternotomy. There were no deaths in the seven patients who received either a third or fourth sternotomy.

"The main finding in our study is that repeat sternotomy is not a predictor of operative mortality for isolated surgical aortic ," says Dr. Greason. "Repeat sternotomy and surgical can be done with low risk in patients in their 80s." He observes however that "These patients were operated on at a high-volume center and were selected for operation by a group of surgeons well versed in complex reoperative cardiac surgical procedures, so these results may not be reproducible at centers without the same degree of experience. An option may be to refer these patients to a specialist center."

Explore further: First human totally endoscopic aortic valve replacements reported

More information: "Repeat sternotomy for surgical aortic valve replacement in octogenarian patients with aortic valve stenosis and previous coronary artery bypass graft operation: What is the operative risk?" by Sebastian A. Iturra, MD; Kevin L. Greason, MD; Rakesh M. Suri, MD; Lyle D. Joyce, MD; John M. Stulak, MD; Alberto Pochettino, MD; and Hartzell V. Schaff, MD DOI: dx.doi.org/10.1016/j.jtcvs.2013.11.048

Related Stories

First human totally endoscopic aortic valve replacements reported

March 11, 2014
Surgeons in France have successfully replaced the aortic valve in two patients without opening the chest during surgery. The procedure, using totally endoscopic aortic valve replacement (TEAVR), shows potential for improving ...

TAVI is safe alternative to redo cardiac surgery

September 2, 2013
TAVI is a safe alternative to redo cardiac surgery for failing bioprosthetic valves, according to research presented at the ESC Congress today by Dr. Spyridon Katsanos from the Netherlands. The findings suggest that transcatheter ...

Rate of aortic valve replacement for elderly patients has increased; outcomes improved

November 17, 2013
Jose Augusto Barreto-Filho, M.D., Ph.D., of the Federal University of Sergipe and the Clinica e Hospital Sao Lucas, Sergipe, Brazil, and colleagues assessed procedure rates and outcomes of surgical aortic valve replacement ...

Availability of transcatheter repair of aortic stenosis benefits patients

January 30, 2014
The introduction of minimally invasive transcatheter aortic valve replacement (TAVR) for treatment of aortic stenos not only has increased the number of patients eligible for aortic valve replacement (AVR), but also has led ...

Results of the COREVALVE EXTREME RISK trial presented

October 29, 2013
In a clinical trial, a self-expanding transcatheter aortic valve met the key performance objective of reducing death and stroke in patients with severe aortic stenosis at "extreme risk" for surgery.Results of the COREVALVE ...

Minimally-invasive failed biological aortic valve replacement successful in high risk patients

May 6, 2013
When a biologic aortic valve prosthesis fails, the patient often faces a high risk valve replacement through repeat open heart surgery. A new technique, known as Valve-in-Valve, uses minimally invasive techniques to introduce ...

Recommended for you

A better clot-buster drug for strokes?

April 26, 2018
(HealthDay)—After a stroke, many patients are given the clot-busting intravenous drug alteplase, but another drug may be more effective, Australian researchers report.

Imaging may allow safe tPA treatment of patients with unwitnessed strokes

April 25, 2018
A study led by Massachusetts General Hospital (MGH) investigators may lead to a significant expansion in the number of stroke patients who can safely be treated with intravenous tPA (tissue plasminogen activator), the "clot ...

Mice make over four times as many new heart muscle cells when they exercise, study finds

April 25, 2018
Doctors, health organizations, and the Surgeon General all agree that exercise is good for the heart—but the reasons why are still not well understood.

Heart disease may only be a matter of time for those with healthy obesity

April 24, 2018
People who are 30 pounds or more overweight may want to slim down a bit even if they don't have high blood pressure or any other heart disease risk, according to scientists at Wake Forest Baptist Medical Center.

Women at greater risk of stress-induced ischemia after heart attacks

April 24, 2018
Women who've previously experienced a heart attack have twice the risk of later myocardial ischemia provoked by mental stress when compared to men with a similar history, according to a study published in Circulation.

A wearable device intervention to increase exercise in peripheral artery disease

April 24, 2018
A home-based exercise program, consisting of wearable devices and telephone coaching, did not improve walking ability for patients with peripheral artery disease, according to a new Northwestern Medicine study.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.