Reoperative Surgery Volumes and Outcomes

Podcast Transcript

Announcer:

Welcome to Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic. This podcast will explore the latest innovations, medical and surgical treatments, diagnostic testing, research, technology and practice improvements. 

Shinya Unai, MD:

I'd like to present our results of operations.

We performed over 1,100 operations last year and 290 multi-redo heart surgeries. 50 patients had their fourth or more reoperative heart surgery at Cleveland Clinic

Outcomes have been excellent. Over the last several years, our mortality has been ranging around 2 to 3% for our reoperations. Within the STS category cases, we had one death for redo CABG but no other mortalities among the 233 STS category cases.

Between 2020 and 2024, redo isolated CABG and MVR, the mortality has been around 1%, which is much lower compared to the STS data, which is ranging around 3 to 6%. For isolated redo mitral valve repair, we have had no deaths.

Endocarditis surgery has been increasing. Last year, we performed about 230 surgeries and the mortality has been around 3%. Considering many of these patients are reoperations and very complex, require root reconstruction, I think this is an excellent outcome.

That's about 60-80 homograft root replacements every year, again, with excellent outcomes.

Based on this large experience in endocarditis, we published a book just about endocarditis, over 600 pages. This project started in 2020. We exchanged over 1,000 emails, and it was finally published about a week ago. On behalf of Doctor Petterson, thanks to all the coauthors.

TAVR explant surgery is another topic that has been discussed at every single major cardiac meeting. Our mortality has been around 5%, which is much lower than what is reported from other centers, which is about 10 to 20% mortality.

In Ross procedures, the number has been increasing at our institution as well. Last year we performed over 30 cases. Some of these are reoperations that have had multiple aortic valve surgeries. For some patients, this may be the only good operation.

I would like to show one example. This is a patient we operated on last year, a who had four prior open heart surgeries. Over the years, she had an AVR, a redo AVR, and a third redo Homograft. The last two surgeries were for endocarditis, which failed. Then she had a fourth redo root replacement.

This is a very complex operation that required a Cabrol graft. She was open just for a few days. She presented with severe aortic stenosis. One of her discs was not moving well. In addition, she had moderate mitral regurgitation and tricuspid regurgitation. Her distal aortic anastomosis had a kink. Her left main had kink as well.

At her local center, she was told that heart transplant was the only option. I got a second opinion. I looked at the imaging, I discussed with Dr. Petterson and we thought we could fix the valves. She doesn't need a heart transplant. What we did was a fifth redo surgery, circulatory arrest, hemiarch replacement, Ross procedure and mitral valve and tricuspid valve repair. Her outflow tract was about 16 mm. She had a large pannus, a lot of surgical material. After we removed all that, it was still very narrow. So, we had to enlarge the LVOT with the mini Konno incision. Cross time was three hours and 50 minutes. It was about five hours or so. But at the end, the LV and RV function was both normal, with no AI. She was extubated on day one, discharged on day ten. I saw her a few weeks ago in follow up. She had no AI and normal LV/RV function. She said that she can do everything she wants.

This kind of complex operation can only be done with a very excellent team of teams. I'm grateful to have a great team, not only during the day, but also during the night as well. Because these cases go well into the night. Recently, they started assigning two fellows on my service so that they don't burn out. Without you guys, this cannot be done, and they've done a very good job, so thank you.

Thanks to Dr. Petterson for coming back every few months to continue to teach us. Whenever he comes back, he's probably the hardest-working surgeon. This was a picture that was taken around 2 a.m. on Friday night after he had probably done 2 or 3 surgeries during the day.

I called him around midnight and told him that we have an offer for a lung transplant that could be a suitable candidate for a BAR (bronchial artery revascularization), which has been his sort of life work. So, I called him around midnight, he woke up, came to the O.R. and we did another six-hour pump run surgery that went well.

We hope that he'll continue to come back and teach us how to handle these very complex situations. So, thank you.

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