Early and late prognosis after reoperation for prosthetic valve replacement

From 1969 to 1983, 89 patients underwent replacement of a prosthetic heart valve, an average of 66 months after initial implantation, because of primary failure of the prosthesis in 39 patients (44%), endocarditis in 16 (18%), systemic valve-related complications in 16 (18%), and periprosthetic leaks in 13 (15%). In the remaining five patients (5%), a prosthesis was removed concomitantly with the replacement of another native heart valve. A mechanical valve was replaced in 64 cases (72%) and a bioprosthesis in 25 (28%). Forty-six of the prostheses (52%) were in the mitral position, 37 (42%) were in the aortic position, and six patients (6%) underwent replacement of two prostheses. Preoperatively, four patients were in Functional Class I, 21 in Class II, 37 in Class III, and 27 in Class IV. There were 19 early deaths (21.3%). Early mortality was significantly higher with aortic (35.1%) than with mitral prosthetic valve replacement (8.7%, p less than 0.01). Preoperative diagnosis had a significant correlation with mortality, which was higher with infective endocarditis (62.5%) than with all other indications for operation (12.3%, p less than 0.001). No correlation was found with the preoperative clinical class of the patients. During the time period of this study, there was a marked decline in the mortality rate, which decreased from 29.2% prior to 1979 to 7.4% during the last 2 years (p less than 0.05). Actuarial survival was 60% at 5 years and 38% at 10 years after reoperation. Among the 53 survivors followed up for an average of 39 months, 47 (88.9%) remained in Class I or II and six were in Class III (11.3%) at last follow-up. A second prosthetic valve replacement (third valve replacement) was required in eight patients, three of whom died at re-replacement. Recent improvements in myocardial protection techniques, in the treatment of prosthetic valve endocarditis, and increased surgical experience have contributed to decrease the risk of reoperation for prosthetic valve replacement. Late results are similar to those of a first valve implantation.