Skip to Main Content


The number of patients undergoing reoperation for valvular heart disease is increasing and will continue to increase as the general population ages.1 These reoperations most commonly involve structural deterioration of a bioprosthesis or progression of native-valve disease after nonvalve surgery. In fact, structural failure of a biologic valve should be considered part of the natural evolution of tissue valves and should be fully appreciated by both the surgeon and the patient prior to implantation.2 Reoperations are technically more difficult than primary operations because of adhesions around the heart with an associated risk of reentry, the presence of more advanced cardiac pathology, and the existence of more frequent comorbidities such as pulmonary hypertension. Perhaps most important, reoperative replacement operations often are performed in functionally compromised patients who tolerate complications poorly or who have little reserve.3 As a consequence of these and other factors, reoperative valve surgery historically has been associated with a considerably higher operative mortality than primary valve surgery, particularly in patients who have had multiple prior replacements.4 In the modern era, however, with the use of alternative surgical approaches and advanced perioperative care, there has been significant improvement in outcomes.5–9


Reductions in operative risk and postoperative morbidity after reoperative valve surgery have been made in the past few years through advances in myocardial protection, as well as alternative perfusion strategies such as the proper use of deep hypothermic cardiac arrest.10 In addition, use of peripheral cannulation techniques to institute cardiopulmonary bypass has become a relatively standard practice in reoperative cases.11–13 Early institution of cardiopulmonary bypass prior to reentry is known to prevent injury to the distended right ventricle or patent coronary artery bypass grafts during reoperative sternotomy. In addition, this technique reduces myocardial oxygen consumption by decreasing myocardial distension.4


Successful replacement of the degenerate cardiac valve usually results in gratifying symptomatic and hemodynamic improvement. Maintenance of this improved state, however, depends on persistence of prosthetic valve function. In this regard, improvements in valve design have mitigated but not eliminated primary bioprosthetic failure.14–16 As such, the risk of re-replacement for bioprosthetic failure remains a significant factor to be considered in the selection of valve type for implantation.17


The most appropriate valve substitute for an individual patient remains a source of much controversy. This choice should be adapted to each individual patient depending on age, life expectancy, valve size, and cardiac as well as noncardiac comorbidities.18 Some studies comparing the long-term outcomes between biologic and mechanical aortic valve prostheses have yielded similar results with regard to overall valve-related complications.19–22 However, most recent large studies have documented that anticoagulant-related bleeding with mechanical valves must be balanced against life expectation and the risk of biologic valve re-replacement.23–25 Bioprosthetic valves are known to undergo a time-dependent process of structural deterioration that results in a freedom of reoperation of 80% at 15 years.20 Consequently, structural degeneration of a bioprosthesis ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessSurgery Full Site: One-Year Subscription

Connect to the full suite of AccessSurgery content and resources including more than 160 instructional videos, 16,000+ high-quality images, interactive board review, 20+ textbooks, and more.

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessSurgery

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.