Vinay, M Rao (2010) Reoperative valve surgery: A Retrospective analysis of last ten years. Masters thesis, Christian Medical College, Vellore.
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Abstract
INTRODUCTION: Extensive advances have been made in cardiac valve surgery since the first artificial valve replacements of the early 1950s. Improved survival after the first operation has meant that more patients ultimately require a redo operation at the same site and the number of patients will continue to increase as the general population ages. This trend reflects many factors, such as the increased life expectancy of the population, the decreased overall mortality associated with valvular surgery, and the increasing use of bioprostheses which have limited durability because of structural dysfunction. Hence reoperations are an integral part of the cardiac surgeon’s current daily practice. Among heart valves case load, re-operations on prostheses represent between 2.5% and 17%. AIMS AND OBJECTIVES: 1. To retrospectively evaluate our experience in patients who underwent re-operative valve surgery in our institution between January 2000 and December 2009 (a period of ten years). 2. To study their manner of presentation, the reasons leading to reoperation, the type of surgery performed and operative techniques. 3. To identify the risk factors for early mortality and morbidity associated with these operations. 4. To study the incidence of late morbidity and functional class at last follow-up. MATERIAL AND METHODS: This is a retrospective study of patients who underwent re-operative valve surgery between January 2000 and December 2009 in the Department of cardiothoracic surgery. In this period, a total of 43 underwent a first reoperation for a new valve problem of the native/prosthetic valve. There were 5 operative (30 days) mortalities (11.62%). A retrospective review of the hospital inpatient and outpatient charts of the rest of the 38 patients for their age, sex, presenting symptoms, preoperative NYHA class, preoperative risk factors, echocardiogram reports and operative details including surgical approach, total aortic cross clamp time, total cardio-pulmonary bypass time, post operative need for inotropes and ventilation, number of days of ICU care, post operative complications and post operative follow up was performed.(See appendix for proforma of data collection). Six patients were lost in the follow-up. Patients who had undergone a previous open heart surgery for varied etiologies were included in the study. Coronary angiogram was done in all patients older than 40 years. CONCLUSION: In conclusion, we have shown in this small series that repeat heart valve surgery can be performed with an acceptable operative mortality that compares favorably with results in other published series. However, several categories of patients have an increased risk of death at reoperation. These include patients with higher NYHA class, surgical priority, presence of infective endocarditis, preoperative renal dysfunction, Presence of CCF, preoperative LV function, previous surgery, present indication for reoperation and total CPB time. In addition, the indication for reoperation, especially thrombosed valves or prosthetic valve endocarditis, carries an increased risk. It is important that patients with prosthetic valves undergo regular follow-up with assessment of valve function and should undergo earlier reoperation before severe ventricular dysfunction occurs. In spite of regular follow-up, it is noted that majority of patients present with severe symptoms at reoperation, which is a predictor of major adverse postoperative event, including death, after valve reoperation. Hence, surgery should be considered early in the management of recurrent or progressive cardiac disease before severe symptoms develop and compromise the outcome of reoperation. In patients undergoing re-operative surgery, our unit protocol is to establish cardiopulmonary bypass before resternotomy and this is a valid and reproducible option to render cardiac reoperations safer and more expeditious in the reentry phase. The absence of cannulae in the operating field makes the procedure more comfortable. The liberal use of this strategy is recommended in redo cases is recommended. In our experience, there was no single instance of catastrophic hemorrhage and also it results in decreased total operative times and also decreased need for blood transfusions. No patient experienced complications related to femoral cannulation. The Seldinger method allowed little vascular trauma and intraoperative patency of femoral vessels. Reoperative surgery continues to pose a significant challenge to the entire cardiothoracic team. Careful patient selection and assessment, a tailored strategy based on accurate risk stratification, and a team approach in the perioperative period can decrease the incidence of adverse events, reducing morbidity and mortality. Further minimization of the risk is obtained by strict adherence to sound basic surgical principles and techniques. Generally speaking, optimal planning for reoperation prior to deterioration to NYHA class III–IV levels and before unfavorable co-morbid conditions have arisen is imperative to ensure good outcomes. Following these guidelines in the modern era, elective reoperative surgery can be performed with results similar to those of the primary operation.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Reoperative valve surgery, Retrospective analysis, ten years. |
| Subjects: | MEDICAL > Cardio Vascular and Thoracic Surgery |
| Depositing User: | Subramani R |
| Date Deposited: | 11 Feb 2020 03:09 |
| Last Modified: | 11 Feb 2020 03:09 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/11909 |
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