Reoperative Cardiac Surgery Update

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Shinya Unai, MD:

Hi. So, I would like to present the results of our reoperative heart surgery last year. So last year, we performed a total of over 5,000 heart surgeries, and 1,123 of them were reoperations. And 260 patients had multi-redo surgery, meaning a third or more heart surgeries at the Cleveland Clinic. And 21 patients had their fifth or more heart surgery here.

The outcomes have been excellent over the last several years. The mortality rate has been about 2 percent to 3 percent. And within all STS categories, the observed mortality was lower than predicted. And for isolated redo CABG, redo aortic valve replacement and mitral valve repair, the mortality has been zero. The number of patients that had surgery for endocarditis has been increasing. Last year, we performed over 200 surgeries for endocarditis. Many of these patients come with aortic root abscess and require complex root reconstructions, but the mortality has been excellent, around 2 percent to 3 percent. And many of them require a homograft root replacement. We do about 60 to 100 of them every year. Again, the outcomes have been great.

And over the last 30 years, we performed over 2000 homograft implants, and we published our experience of that and showed safety and good durability comparable to bioprosthetic valves.

And the risk of reinfection was low. And there's another manuscript accepted for publication regarding the reoperation after homograft implant. After eight to 10 years, these homografts tend to calcify, and it looks like this, but reoperation can be done safely with an overall mortality of about 3 percent. However, there are still a lot of presentations and publications questioning the use of homografts. And this is a presentation that was done recently at a national meeting from a prestigious academic center. The title was, Homograft Root Replacement Does Not Provide Superior Outcomes in Invasive Aortic Valve Endocarditis. The number was low, the mortality was high, and there was really no matching between the comparison groups. And Dr. Eric Roselli stood up and said, "Your study is flawed." Another paper titled, Graft Selection for Aortic Root Replacement in Complex Active Endocarditis Doesn't Matter. It does matter. When you have aortic endocarditis with a root abscess like this, circumferential in a big hole connecting the radiation into the LVOT, there's really no other good choice than to use a homograft. So, we need to do a lot of education in this area.

I just want to show one example of a patient that we operated on. So, this was a 69-year-old gentleman with prosthetic valve endocarditis. He had two prior history of mitral valve replacement, 2008 and 2010. He was diagnosed with prosthetic valve endocarditis in 2017, was started on suppressive antibiotics since then. He has several embolic events, including a subarachnoid hemorrhage, but was continued on antibiotics. In June 2019, he had severe mitral regurgitation. Again, admitted and was placed on antibiotics. I relapsed again after a month or so with fever and lumbar discitis. His TEE was stable, so the decision was made to conservatively manage this patient, who was very active and goes to gym three to five times a week, does pickleball, skiing, but deemed not a surgical candidate because of the surgical complexity. So, he decided to come to Cleveland Clinic for a second opinion.

So, I did his third redo sternotomy, aortic valve, mitral valve, tricuspid valve, Maze, CABG, a fairly complex surgery, but it's something that we do almost every day. It was actually my third case of the day, and it went very well. He came out of the OR on minimal inotropic support. He was extubated the following morning, and when I routed around 6:30 AM, he was already joking around, feeling great. He was transferred to step down on day three, and this is how the valve looked. So, it turns out that this patient was a founder of the Vietnam Wall, and this story was reported on several news medias. He continues to do well. He skis in Colorado, skeet shooting, golfing every week.

So, to have good outcomes with a redo surgery requires a good team, and advice and help from senior surgeons is really important. We looked at the reoperations done at the Cleveland Clinic. And we found out that as you gain more experience, your mortality goes down. And as you age, your mortality goes down. There's only one surgeon that has done over 4,000 reoperations in over 70 years of age. His name is Gosta Pettersson. We are very lucky to have him come back every few months to continue to teach us how to deal with these complex situations. And of course, I'm very grateful to have an exceptional team inside and outside of the OR. Nurses, PAs and techs and perfusionists and all the residents and fellows that come through my rotation have done a great job. They're all smiling in this picture, but at the end of three months, some of them are not really smiling. Some of them lose weight. But hopefully they have learned something. And thanks for all you do.

Announcer:

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