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Central Surgical Association

49th Annual Meeting

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Impact of Prior Aortic Surgery on Clinical Outcomes for Infective Endocarditis Requiring Reoperative Aortic Root Replacement
Dov Levine1, Parth M. Patel2, Yanling Zhao1, Andy Dong2, Paul A. Kurlansky1, Bradley G. Leshnower2, Edward P. Chen3, Hiroo Takayama1
1Columbia University Irving Medical Center, New York, New York, United States, 2Emory University School of Medicine, Atlanta, Georgia, United States, 3Duke University, Durham, North Carolina, United States

Objective: The influence of prior aortic surgery with aortic graft on prosthetic valve or graft endocarditis requiring aortic root replacement (ARR) is largely unknown. We examined and compared short- and long-term outcomes in patients requiring reoperative ARR for infective endocarditis (IE) following prior aortic valve replacement (AVR) and/or prior aortic surgery. Independent risk factors for in-hospital mortality were also identified.
Methods: This is a two-center retrospective study involving 143 patients undergoing reoperative ARR for IE between 2004-2021. Patients were divided into two groups based on presence or absence of aortic graft: prior aortic surgery (AO, n=70) and prior AVR alone (AV, n=73). The primary end point was in-hospital mortality. Inverse propensity treatment weighting (IPTW) was performed using baseline characteristics to match each group. Survival distributions of AO and AV groups were estimated by the Kaplan-Meier methods. Fine and Gray model was used to estimate and compare the cumulative incidence of all-cause reintervention between groups. Univariable and multivariable analyses were performed by logistic regression to identify independent factors associated with in-hospital mortality.
Results: Within AO patients, 71.4% had previously undergone root, 70.0% ascending, and 34.3% arch replacement, and 85.7% had a prosthetic aortic valve. Urgent or emergent surgery was performed in 80.0% of cases. A total of 54 (77.1%) patients received bio-Bentall, 17.1% mechanical Bentall, 2.9% homograft, 1.4% Ross, and 1.4% valve sparing root replacement. Hemiarch replacement occurred in 55.7%. Compared to AV patients after IPTW adjustment, AO patients had similar in-hospital mortality (23.3% AO vs 16.4% AV, p=.326), but increased incidence of stroke (12.8% vs 1.0%, p=.011) and acute renal failure (22.9% vs 7.1%, p=.009). Baseline characteristics independently associated with mortality included age (OR 1.05, 95% CI 1.01-1.10), chronic kidney disease (OR 3.20, 95% CI 1.27-8.09), and cardiogenic shock (OR 7.29, 95% CI 1.35-39.4), but not presence of aortic graft (OR 1.33, 95% CI 0.53-3.34) (Table 1). Five-year matched survival was 66.2% (95% CI 54.3%-80.7%) in AO and 63.9% (95% CI 47.6%-85.9%) in AV (p=.86). Cumulative incidence of reintervention was not different between groups (AO 6.8%, 95% CI 1.7%-24.7%% vs AV 16.9%, 95% CI 5.6%-44.9%, p=.55).
Conclusions: Reoperative ARR for prosthetic valve/graft endocarditis is a high-risk procedure. Patients with prior aortic surgery required a more complex concomitant arch intervention and ultimately had a higher incidence of post-operative morbidity; however, the presence of a prior aortic graft did not negatively impact in-hospital mortality. For patients surviving operative intervention, five-year survival and reintervention rates were comparable between groups.


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