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Hardy WA, Kang L, Turek JW, Rajab TK. Outcomes of truncal valve replacement in neonates and infants: a meta-analysis. Cardiol Young 2023; 33:673-680. [PMID: 36970855 DOI: 10.1017/s1047951123000604] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Infants with truncus arteriosus typically undergo repair by repurposing the truncal valve as the neo-aortic valve and using a valved conduit homograft for the neo-pulmonary valve. In cases where the native truncal valve is too insufficient for repair, it is replaced, but this is a rare occurrence with a paucity of data, especially in the infant population. Here, we conduct a meta-analysis to better understand the outcomes of infant truncal valve replacement during the primary repair of truncus arteriosus. METHODS We systematically reviewed PubMed, Scopus, and CINAHL for all studies reporting infant (<12 months) truncus arteriosus outcomes between 1974 and 2021. Exclusion criteria were studies which did not report truncal valve replacement outcomes separately. Data extracted included valve replacement type, mortality, and reintervention. Our primary outcome was early mortality, and our secondary outcomes were late mortality and reintervention rates. RESULTS Sixteen studies with 41 infants who underwent truncal valve replacement were included. The truncal valve replacement types were homografts (68.8%), mechanical valves (28.1%), and bioprosthetic valves (3.1%). Overall early mortality was 49.4% (95% CI: 28.4-70.5). The pooled late mortality rate was 15.3%/year (95% CI: 5.8-40.7). The overall rate of truncal valve reintervention was 21.7%/year (95% CI: 8.4-55.7). CONCLUSIONS Infant truncal valve replacement has poor early and late mortality as well as high rates of reintervention. Truncal valve replacement therefore remains an unsolved problem in congenital cardiac surgery. Innovations in congenital cardiac surgery, such as partial heart transplantation, are required to address this.
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Affiliation(s)
- William A Hardy
- Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Lillian Kang
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Joseph W Turek
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - T Konrad Rajab
- Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
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Abstract
Application of the original vitrification protocol used for pieces of heart valves to intact heart valves has evolved over time. Ice-free cryopreservation by Protocol 1 using VS55 is limited to small samples (1-3 mL total volume) where relatively rapid cooling and warming rates are possible. VS55 cryopreservation typically provides extracellular matrix preservation with approximately 80% cell viability and tissue function compared with fresh untreated tissues. In contrast, ice-free cryopreservation using VS83, Protocols 2 and 3, permits preservation of large samples (80-100 mL total volume) with several advantages over conventional cryopreservation methods and VS55 preservation, including long-term preservation capability at -80 °C; better matrix preservation than freezing with retention of material properties; very low cell viability, reducing the risks of an immune reaction in vivo; reduced risks of microbial contamination associated with use of liquid nitrogen; improved in vivo functions; no significant recipient allogeneic immune response; simplified manufacturing process; increased operator safety because liquid nitrogen is not used; and reduced manufacturing costs. More recently, we have developed Protocol 4 in which VS55 is supplemented with sugars resulting in reduced concerns regarding nucleation during cooling and warming. This method can be used for large samples resulting in retention of cell viability and permits short-term exposure to -80 °C with long-term storage preferred at or below -135 °C.
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Udelsman B, Mathisen DJ, Ott HC. A reassessment of tracheal substitutes-a systematic review. Ann Cardiothorac Surg 2018. [PMID: 29707495 DOI: 10.21037/acs.2018.01.17.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Tracheal substitutes remain an active area of research. For rare patients with large or complex defects that cannot be repaired primarily, replacement of the airway may represent the only treatment option. The present systematic review aims to assess the clinical successes and setbacks of current methods of airway replacement. Methods Systematic review using Medline and PubMed from 01 January 2000 to 01 October 2017 focusing on clinical translation of circumferential or near circumferential (>270°) tracheal substitutes. Studies were identified using key phrases including terms such as "tracheal replacement", "tracheal regeneration", "tracheal transplant", "tracheal tissue engineering", and "tracheal substitution". Animal or non-clinical studies were excluded. Reviews were included if they contained clinical updates. Results Twenty-one studies were included in assessment comprising a mix of case reports, case studies, and a single review with clinical updates on prior studies. Since 2001, 41 patients have undergone a reported circumferential or near circumferential tracheal substitution through four underlying methodologies including allotransplantation, autologous tissue reconstruction, bioprosthetic reconstruction, and tissue engineered reconstruction. Each modality has unique advantages and disadvantages with varying success in clinical application. Conclusions The need for tracheal substitution remains a difficult clinical problem without an ideal prosthetic or graft material. While various modalities have had limited clinical success, further laboratory work is necessary before tracheal substitutes can become widely adopted, especially in the case of tissue engineered conduits, which have been setback by premature clinical translation.
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Affiliation(s)
- Brooks Udelsman
- Division of General Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Harald C Ott
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Udelsman B, Mathisen DJ, Ott HC. A reassessment of tracheal substitutes-a systematic review. Ann Cardiothorac Surg 2018; 7:175-182. [PMID: 29707495 DOI: 10.21037/acs.2018.01.17] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Tracheal substitutes remain an active area of research. For rare patients with large or complex defects that cannot be repaired primarily, replacement of the airway may represent the only treatment option. The present systematic review aims to assess the clinical successes and setbacks of current methods of airway replacement. Methods Systematic review using Medline and PubMed from 01 January 2000 to 01 October 2017 focusing on clinical translation of circumferential or near circumferential (>270°) tracheal substitutes. Studies were identified using key phrases including terms such as "tracheal replacement", "tracheal regeneration", "tracheal transplant", "tracheal tissue engineering", and "tracheal substitution". Animal or non-clinical studies were excluded. Reviews were included if they contained clinical updates. Results Twenty-one studies were included in assessment comprising a mix of case reports, case studies, and a single review with clinical updates on prior studies. Since 2001, 41 patients have undergone a reported circumferential or near circumferential tracheal substitution through four underlying methodologies including allotransplantation, autologous tissue reconstruction, bioprosthetic reconstruction, and tissue engineered reconstruction. Each modality has unique advantages and disadvantages with varying success in clinical application. Conclusions The need for tracheal substitution remains a difficult clinical problem without an ideal prosthetic or graft material. While various modalities have had limited clinical success, further laboratory work is necessary before tracheal substitutes can become widely adopted, especially in the case of tissue engineered conduits, which have been setback by premature clinical translation.
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Affiliation(s)
- Brooks Udelsman
- Division of General Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Harald C Ott
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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5
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Udelsman B, Mathisen DJ, Ott HC. Bioprosthetics and repair of complex aerodigestive defects. Ann Cardiothorac Surg 2018; 7:284-292. [PMID: 29707507 DOI: 10.21037/acs.2018.01.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Aerodigestive defects involving the trachea, bronchi and esophagus are a result of prolonged intubation, operative complications, congenital defects, trauma, radiation and neoplastic disease. The vast majority of these defects may be repaired primarily. Rarely, due the size of the defect, underlying complexity, or unfavorable patient characteristics, primary repair is not possible. One alternative to primary repair is bioprosthetic repair. Materials such as acellular dermal matrix and aortic homograft have been used in a variety of applications, including closure of tracheal, bronchial and esophageal defects. Herein, we review the use of bioprosthetics in the repair of aerodigestive defects, along with the unique advantages and disadvantages of these repairs.
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Affiliation(s)
- Brooks Udelsman
- Division of General Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Harald C Ott
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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6
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Lisy M, Kalender G, Schenke-Layland K, Brockbank KG, Biermann A, Stock UA. Allograft Heart Valves: Current Aspects and Future Applications. Biopreserv Biobank 2017; 15:148-157. [DOI: 10.1089/bio.2016.0070] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Milan Lisy
- Department of General, Visceral, Thoracic and Vascular Surgery, Frankfurt-Höchst City Hospital, Frankfurt am Main, Germany
| | - Guenay Kalender
- Department of General, Visceral, Thoracic and Vascular Surgery, Frankfurt-Höchst City Hospital, Frankfurt am Main, Germany
| | - Katja Schenke-Layland
- Department of Cell and Tissue Engineering, Fraunhofer Institute for Interfacial Engineering, Stuttgart, Germany
- Department of Women's Health, Research Institute for Women's Health, University Tuebingen, Tuebingen, Germany
- Cardiovascular Research Laboratories, Department of Medicine/Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Kelvin G.M. Brockbank
- Tissue Testing Technologies LLC, North Charleston, South Carolina
- Department of Bioengineering, Clemson University, Clemson, South Carolina
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, South Carolina
| | - Anna Biermann
- Department of Thoracic, Cardiac and Thoracic Vascular Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Ulrich Alfred Stock
- Department of Thoracic, Cardiac and Thoracic Vascular Surgery, University Hospital Frankfurt, Frankfurt, Germany
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7
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Cebotari S, Tudorache I, Ciubotaru A, Boethig D, Sarikouch S, Goerler A, Lichtenberg A, Cheptanaru E, Barnaciuc S, Cazacu A, Maliga O, Repin O, Maniuc L, Breymann T, Haverich A. Use of fresh decellularized allografts for pulmonary valve replacement may reduce the reoperation rate in children and young adults: early report. Circulation 2011; 124:S115-23. [PMID: 21911800 DOI: 10.1161/circulationaha.110.012161] [Citation(s) in RCA: 173] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Degeneration of xenografts or homografts is a major cause for reoperation in young patients after pulmonary valve replacement. We present the early results of fresh decellularized pulmonary homografts (DPH) implantation compared with glutaraldehyde-fixed bovine jugular vein (BJV) and cryopreserved homografts (CH). METHODS AND RESULTS Thirty-eight patients with DPH in pulmonary position were consecutively evaluated during the follow-up (up to 5 years) including medical examination, echocardiography, and MRI. These patients were matched according to age and pathology and compared with BJV (n=38) and CH (n=38) recipients. In contrast to BJV and CH groups, echocardiography revealed no increase of transvalvular gradient, cusp thickening, or aneurysmatic dilatation in DPH patients. Over time, DPH valve annulus diameters converge toward normal z-values. Five-year freedom from explantation was 100% for DPH and 86 ± 8% and 88 ± 7% for BJV and CH conduits, respectively. Additionally, MRI investigations in 17 DPH patients with follow-up time >2 years were compared with MRI data of 20 BJV recipients. Both patient groups (DPH and BJV) were at comparable ages (mean, 12.7 ± 6.1 versus 13.0 ± 3.0 years) and have comparable follow-up time (3.7 ± 1.0 versus 2.7 ± 0.9 years). In DPH patients, the mean transvalvular gradient was significantly (P=0.001) lower (11 mm Hg) compared with the BJV group (23.2 mm Hg). Regurgitation fraction was 14 ± 3% and 4 ± 5% in DPH and BJV groups, respectively. In 3 DPH recipients, moderate regurgitation was documented after surgery and remained unchanged in follow-up. CONCLUSIONS In contrast to conventional homografts and xenografts, decellularized fresh allograft valves showed improved freedom from explantation, provided low gradients in follow-up, and exhibited adaptive growth.
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Affiliation(s)
- Serghei Cebotari
- Department of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany.
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Campbell L, Brockbank K. Cryopreservation of Porcine Aortic Heart Valve Leaflet-Derived Myofibroblasts. Biopreserv Biobank 2010; 8:211-7. [DOI: 10.1089/bio.2010.0023] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- L.H. Campbell
- Cell & Tissue Systems, Inc., North Charleston, South Carolina
| | - K.G.M. Brockbank
- Cell & Tissue Systems, Inc., North Charleston, South Carolina
- The Georgia Tech/Emory Center for the Engineering of Living Tissues, Atlanta, Georgia
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9
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Abstract
BACKGROUND Cryopreserved human heart valves are used in approximately 20% of the tissue heart valve procedures performed annually. The pathophysiology of allograft failure is not fully understood. The authors proposed the hypothesis that the rapid deterioration observed in some allograft heart valve recipients is caused by disruptive interstitial ice damage that occurs during cryopreservation and subsequently leads to accelerated valve degeneration on implantation. METHODS This hypothesis was tested by comparison of the standard commercial heart valve freezing method of cryopreservation and an ice-free, vitrification method of cryopreservation with fresh controls in a subcutaneous, juvenile rat implant model of calcification. Calcium concentration in explants was determined by atomic absorption spectroscopy. RESULTS Statistically significant calcification (P<0.05) was observed in both syngeneic and allogeneic cryopreserved valves relative to fresh valves. The ice-free cryopreservation method demonstrated significant reduction of allogeneic heart valve calcification (P<0.01). Comparison of fresh syngeneic and allogeneic grafts at the 3-week time point demonstrated significantly higher calcium content in allograft valve explants (P<0.005). CONCLUSIONS These findings demonstrate that allogeneic valve calcification is influenced by two factors, the cryopreservation method used and immunogenicity. Alternative cryopreservation methods that avoid ice formation may improve the in vivo performance of cryopreserved allogeneic heart valves.
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10
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Okur FF, Tavli V, Kayhan B, Kirman M, Atalay CS, Tekdoğan M. Blalock-Taussig Shunt Using Fresh Saphenous Vein Homograft. Asian Cardiovasc Thorac Ann 2000. [DOI: 10.1177/021849230000800310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The occurrence of life-threatening early and late complications following the use of expanded polytetrafluoroethylene grafts for modified Blalock-Taussig shunts prompted the application of saphenous vein homografts instead. In 21 patients with cyanotic congenital heart disease, fresh saphenous vein homografts were used for Blalock-Taussig shunts from February 1998. The veins were obtained from blood-group matched patients undergoing coronary bypass grafting in the next operating room. There was no early or late mortality. Clinical and echocardiographic studies showed that all shunts were patent and functioning well at an average follow-up of 11 months. This simple homograft technique has no ischemic time and requires no chemical or antibiotic contact.
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Affiliation(s)
| | - Vedide Tavli
- Department of Pediatric Cardiology Şifa Heart Center I·zmir, Turkey
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11
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Oh CC, Click RL, Orszulak TA, Sinak LJ, Oh JK. Role of intraoperative transesophageal echocardiography in determining aortic annulus diameter in homograft insertion. J Am Soc Echocardiogr 1998; 11:638-42. [PMID: 9657403 DOI: 10.1016/s0894-7317(98)70040-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The sizing of aortic valve (AV) homografts for optimum function requires an accurate measurement of the aortic annulus. Typically, this measurement is obtained directly with sizers in the open aorta. We describe the use of intraoperative transesophageal echocardiography (IOTEE) to measure the aortic annulus and select the appropriate AV homograft before cardiopulmonary bypass and aortic cross-clamping. Thirty-two patients underwent AV homograft insertion between March 1993 and March 1996 and had IOTEE. There were 13 women and 19 men. Mean age was 58 +/- 14 years. IOTEE measurements were satisfactory in sizing in all patients, and no extraordinary surgical measures were necessary to insert the AV homografts. Early postoperative follow-up showed trivial or mild regurgitation of all homografts. Prebypass IOTEE is reliable in guiding the selection of optimal AV homografts.
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Affiliation(s)
- C C Oh
- Department of Cardiology and Internal Medicine, Oregon Health Sciences Center, Portland, USA
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12
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Fiane AE, Lindberg HL, Seem E, Geiran OR. Homografts for right ventricular outflow tract reconstruction in congenital heart disease. SCAND CARDIOVASC J 1998; 31:351-6. [PMID: 9455784 DOI: 10.3109/14017439709075952] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In 49 patients aged 2.2-34.8 (mean 11) years, homografts (20 aortic, 29 pulmonary) were implanted in the right ventricular outflow tract as an isolated procedure or part of corrective surgery for congenital heart disease: tetralogy of Fallot with pulmonary stenosis (23 cases), pulmonary atresia with ventricular septal defect (10 cases) truncus arteriosus (8 cases) or transposition of the great arteries with pulmonary stenosis (8 cases). Previous palliative procedures had been performed on 34 patients, and 37 had undergone repair of right ventricular outflow tract, with one to four sternotomies prior to homograft implantation. Homograft valve sizes ranged from 14 to 25 mm internal diameter. Concomitant intra- or extracardiac procedures were performed in 29 cases. Follow-up was complete at a mean of 3 +/- 0.3 (0-8) years. Early and total mortality was 2.0% (1/49), due to sepsis and multi-organ failure unrelated to the homograft. At follow-up all but one of the patients had an improved New York Heart Association function class. Eight patients (16.3%) with a mean age of 9.2 +/- 1.8 (2.8-15.5) years at implantation had homograft malfunction (stenosis in three, regurgitation in two and combined in three) at follow-up, averaging 4.1 +/- 1.0 (0.4-6.9) years, with no significant difference between aorta and pulmonary homograft subsets. Freedom from structural valve deterioration was 46.6 +/- 22% for pulmonary and 32.3 +/- 21.3% for aortic homografts at the 7-year follow-up (difference not significant). In two patients an aortic homograft was uneventfully replaced. In conclusion, homograft implantation in patients with right ventricular outflow tract obstruction improves function class and can entail low mortality and morbidity, even after multiple previous median sternotomies.
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Affiliation(s)
- A E Fiane
- Department of Surgery A, Rikshospitalet, University of Oslo, Norway
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13
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Abstract
BACKGROUND The Ross operation, first performed in children in 1968, may be the ideal aortic valve replacement. Technical demands of the operation and two valves at risk have delayed acceptance. A review of our experience to assess midterm and long-term results with the Ross operation is presented. METHODS The records of 150 consecutive patients, aged 7 days to 21 years (median age, 12 years, 75% less than 15 years) were reviewed. Follow-up was complete within the last 12 months (median, 2.8 years; range, 1 month to 10 years). Echocardiographic assessment was available on 116 (71%) within 1 year of closure and in 136 (91%) within 2 years. RESULTS Survival was 97.3% at 8 years. Late autograft valve dysfunction required replacement in 2 and reoperation with restitution of autograft function in 6. Freedom from reoperation for autograft dysfunction is 90% +/- 4% at 8 years. Freedom from reoperation for homograft obstruction is 94% +/- 3% at 8 years. Pulmonary homograft dysfunction (gradient > 40 mm Hg) was present in 4 additional patients. Freedom from reoperation on the homograft or a gradient of 40 mm Hg is 89% +/- 4% at 8 years. All patients have a normal, active lifestyle, without anticoagulants for their aortic valve replacement. CONCLUSIONS The Ross operation is the preferred operative replacement in children requiring aortic valve replacement.
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Affiliation(s)
- R C Elkins
- Section of Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190, USA
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Prager RL, Fischer CR, Kong B, Byrne JP, Jones DJ, Hance ML, Gago O. The aortic homograft: evolution of indications, techniques, and results in 107 patients. Ann Thorac Surg 1997; 64:659-63; discussion 663-4. [PMID: 9307453 DOI: 10.1016/s0003-4975(97)00623-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Homograft aortic valve replacement has been performed in 107 patients during the past 7 years. Two primary methods of implantation were used (intraaortic and root replacement). Results of both methods are presented. METHODS Intraaortic implantation (subcoronary or cylinder technique) was performed in 36 patients (mean age, 54 years) for aortic stenosis or regurgitation (31 patients) and endocarditis (5 patients). Aortic root replacement was performed in 71 patients (mean age, 62 years). The majority (58 patients) had complex root pathologies such as ascending aneurysm, dissection, or prosthetic endocarditis with annular destruction. Early results were assessed with intraoperative or predischarge echocardiography; annual echocardiograms provided long-term follow-up. Left ventricular mass was calculated in patients with long-standing pathology for whom preoperative and postoperative data were available. RESULTS Early valvular insufficiency was documented in 16 of the 36 intraaortic implants (44%); 9 of these have had progression of the insufficiency. Of the 20 patients who had trivial or no early insufficiency, significant insufficiency has developed in 7 and mild insufficiency has developed in 5. Calculation of left ventricular mass revealed a mean reduction of 11% at 1 year. There has been no mortality, endocarditis, or homograft-related reoperation in the intraaortic group with a mean follow-up of 50 months. The root replacement group had a hospital mortality of 17%. The cardiac pathology was limited to the aortic valve in 12 patients; mortality in this subset was zero. There has been no significant early or late postoperative valvular insufficiency in the 59 surviving patients. More rapid left ventricular mass reduction was seen in this group with a 26% mean reduction within 1 year. A mean follow-up of 32 months in the root replacement group has seen no homograft-related reoperations. CONCLUSIONS Although the lack of early mortality in the intraaortic group makes this technique appealing, the high incidence of early insufficiency with the realistic expectation of progression has led to our abandonment of the intraaortic technique. Homograft aortic root replacement confers a higher mortality based on the severity of aortic pathology, but offers excellent long-term hemodynamics in any patient. We have expanded our indication for homograft root replacement to include patients with isolated valvular disease rather than reserving it for those patients with extensive root pathology.
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Affiliation(s)
- R L Prager
- Section of Cardiac and Thoracic Surgery, St. Joseph Mercy Hospital, Ann Arbor, Michigan, USA
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15
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Dearani JA, Orszulak TA, Daly RC, Phillips MR, Miller FA, Danielson GK, Schaff HV. Comparison of techniques for implantation of aortic valve allografts. Ann Thorac Surg 1996; 62:1069-75. [PMID: 8823091 DOI: 10.1016/0003-4975(96)00593-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Various implantation techniques for allograft aortic valve replacement have evolved over the years. Our objective was to examine the effects of different implantation methods on subsequent valve performance and durability. METHODS Between May 1985 and January 1994, 137 patients underwent allograft aortic valve replacement. The first 59 aortic valve allografts were inserted by the freehand scalloped technique with removal of the aortic sinuses, and the last 78 valves were inserted by the cylinder technique, in which the aortic sinuses and sinotubular junction were retained. The mean age of the 91 men and 46 women was 53.7 years (range, 18 to 83 years). Preoperative diagnoses were aortic stenosis (n = 57), aortic regurgitation (AR, n = 40) and aortic stenosis/AR (n = 40); 27 patients had prior aortic valve operations and 1 patient had a previous heart transplantation. Active endocarditis was present in 29 patients. Associated procedures included coronary artery bypass (n = 33), ascending aneurysm repair (n = 4), left ventricular aneurysmectomy (n = 3), repair of atrial septal defect (n = 2), mitral valve repair or replacement (n = 6), and aortic root enlargement (n = 24). Follow-up was complete in 133 patients (97%) a mean of 4.9 years (range, 1 day to 9.8 years) after allograft aortic valve replacement. RESULTS Operative mortality was 6.5% for all patients but only 1.9% for patients without infection having isolated aortic valve replacement. Early echocardiography (mean of 8.4 days postoperatively) demonstrated no AR or mild AR and a mean gradient of 10.6 +/- 6.2 mm Hg in all patients. The cumulative risk of development of grade III or IV AR at 7 years postoperatively was 26.2% +/- 6.3% in the scallop group and 12.4% +/- 5.6% in the cylinder group (p = 0.4). Late postoperatively, transvalvular gradient by echocardiography was 13.1 +/- 9.4 mm Hg, and was similar in the two study groups. Late AR led to reoperation in 13 patients (22%) who had initial implantation with the scallop method and only 4 patients (5.4%) who had the valve inserted with the cylinder method. However, because duration of follow-up was longer for patients in the scallop group, cumulative risk of reoperation was similar at 5 years postoperatively (scallop, 13.7% [95% confidence interval, 76.7% to 95.8%]; cylinder, 11.5% [95% confidence interval, 75.5% to 99.1%]). CONCLUSIONS The insertion of an aortic valve allograft as a cylinder, retaining the sinotubular junction, appears to result in less aortic regurgitation at 7 years postoperatively, and with additional follow-up may result in less reoperation for AR.
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Affiliation(s)
- J A Dearani
- Section of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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16
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Tamura K, Jones M, Yamada I, Ferrans VJ. A comparison of failure modes of glutaraldehyde-treated versus antibiotic-preserved mitral valve allografts implanted in sheep. J Thorac Cardiovasc Surg 1995; 110:224-38. [PMID: 7609546 DOI: 10.1016/s0022-5223(05)80029-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Morphologic studies and calcium analyses were made on mitral valve allografts from 12 juvenile sheep surviving 12 to 24 weeks after mitral valve replacement. Before implantation, the allografts were treated with 0.625% glutaraldehyde (group I, n = 4) or with cold antibiotic solution (group II, n = 8). Three group I animals died 12 to 19 weeks after implantation because of dysfunction of calcified valves; the surviving animal also had extensive allograft calcification. One group II animal died of mitral regurgitation; the valves of the other seven (including five with regurgitation shown by Doppler and ventriculographic studies) were explanted at 19 to 24 weeks. Chordal rupture related to calcific deposits was found in all group I valves. Leaflet perforations (n = 4) and ruptured chordae (n = 4), each caused by connective tissue deterioration, were found in group II valves. Inflammatory reaction was absent or minimal in group I valves but moderate or severe in group II valves. Fibrous sheaths were thicker in group II than in group I valves. Calcium levels were much higher in group I than in group II valves. Calcification in group I valves was diffuse and involved collagen, elastic fibers, and connective tissue cells and matrix; in group II valves, it was localized in connective tissue cells. Thus glutaraldehyde-treated allografts failed because of extensive calcification, whereas antibiotic-preserved allografts underwent deterioration of connective tissue and infiltration by inflammatory cells.
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Affiliation(s)
- K Tamura
- Pathology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md. 20892, USA
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Scheld HH, Konertz W. The pathology of bioprosthetic heart valves and allografts. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 1994; 86:87-125. [PMID: 8162715 DOI: 10.1007/978-3-642-76846-0_3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- H H Scheld
- Department of Thoracic and Cardiovascular Surgery, Westphalian Wilhelm's University Münster, Germany
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Abstract
In selected patients, the pulmonary autograft procedure utilizing cryopreserved homografts for reconstruction of the right ventricular outflow tract is becoming an increasingly popular aortic valve replacement alternative. Longitudinal statistical reports show that patients need reoperation less often with this procedure. Because the valve is autogenous tissue, all indications to date show that the valve continues to function for extended periods of time in all patients and can accommodate growth in children. At the same time, transfer of the pulmonary valve to the aortic position provides a natural valvular flow pattern and freedom from the degenerative changes associated with bioprosthetic valves or the need for anticoagulation associated with mechanical valves.
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Affiliation(s)
- P A Wright
- Department of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City
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19
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Abstract
We report a case of severe, crippling juvenile rheumatoid arthritis and aortic insufficiency in a young woman. Homograft replacement of the aortic root offered both long-term durability and the freedom from thromboembolism that her systemic illness required.
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20
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Westaby S, Parry A, Pillai R. Aortic root replacement: modifications of technique with improvements in technology. Eur J Cardiothorac Surg 1992. [DOI: 10.1093/ejcts/6.supplement_1.s44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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Santangelo K, Elkins RC, Stelzer P, Randolph JD, Ward KE, Overholt ED, Thompson WM, Razook JD, Lane M. Normal left ventricular function following pulmonary autograft replacement of the aortic valve in children. J Card Surg 1991; 6:633-7. [PMID: 1810559 DOI: 10.1111/jocs.1991.6.4s.633] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To assess growth potential and hemodynamic sequelae of pulmonary autograft valves implanted into aortic outflow tracts of children, we reviewed our experience with 37 patients (2-21 years) from August 1986 to December 1990. Twenty patients had predominantly aortic stenosis (AS), and 17 had aortic insufficiency (AI). Operative mortality was 3%. Two technical failures required reoperation. Of survivors, six (18%) have moderate AI. Pre- and postoperative echocardiograms were reviewed. The AS group showed increased left ventricular (LV) cavity size by greater than 1-year follow-up, and decreased LV wall and interventricular septal thickness. In the AI group, wall and septal thickness increased by 10 days and LV cavity decreased by 10 days, 60 days, and greater than 1 year. Root replacements (n = 14) showed mean increases of 4.3 mm and 5.3 mm, respectively, in diameters of the aortic annulus and aortic sinuses at greater than 1 year. Intraaortic implants increased 3.1 mm (annulus) and 3.9 mm (sinuses) at greater than 1 year. The pulmonary autograft procedure is safe, and successful implantation normalizes LV dimensions and function rapidly. The autograft valve shows evidence of growth at greater than 1 year postoperative. The pulmonary autograft may be the ideal valve replacement in children.
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Affiliation(s)
- K Santangelo
- The Department of Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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22
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Steinberg JB, Nickell SA, Jacocks MA, Stelzer P. Replacement of the abdominal aorta with an aortic homograft in a patient with an aortic dissection. Ann Vasc Surg 1991; 5:538-41. [PMID: 1772761 DOI: 10.1007/bf02015279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The use of aortic and femoral homografts in early vascular surgery has been abandoned for the more successful and abundant synthetic substitutes. With the recent introduction of cryopreservation, homograft use has again met with improved success. A 40-year-old man who had a DeBakey Type I aortic dissection initially underwent replacement of the aortic root with a pulmonary homograft. Subsequently, in the presence of an intraabdominal infectious process, progressive mesenteric and lower limb ischemia was treated by replacing the abdominal aorta with an aortic homograft. Thirty-six months postoperative the patient has a functioning gastrointestinal tract and no vascular insufficiency of the lower extremities and no evidence of degeneration of the homograft. Further laboratory studies should be undertaken using the newer and improved cyropreserved homograft in the presence of, or potential for, an intraabdominal infectious process.
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Affiliation(s)
- J B Steinberg
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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23
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Glazier JJ, Verwilghen J, Donaldson RM, Ross DN. Treatment of complicated prosthetic aortic valve endocarditis with annular abscess formation by homograft aortic root replacement. J Am Coll Cardiol 1991; 17:1177-82. [PMID: 2007719 DOI: 10.1016/0735-1097(91)90851-y] [Citation(s) in RCA: 103] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The outcome of 30 consecutive patients with active aortic prosthetic valve endocarditis and root abscesses treated by the technique of homograft aortic root replacement with reimplantation of the coronary arteries is detailed. The principles of this technique are the removal of all abscesses and infected areas likely to drain into the infected mediastinum, excision of infected tissues down to healthy noninfected tissue and replacement with an antibiotic-impregnated homograft aortic root. All patients had evidence of progressive cardiac failure and ongoing sepsis. Mean patient age (+/- SD) at the time of operation was 42 +/- 18 years. The mean number of previous aortic valve replacements per patient was 1.6 +/- 0.7; 14 patients (47%) had undergone greater than or equal to 2 previous replacements. At operation, aortic root abscesses were found in all patients; abscess extension to adjacent structures and partial valve dehiscence had occurred in 23. In-hospital death occurred in 9 (30%) of the 30 patients. The 21 hospital survivors have been followed up for a mean of 66 +/- 42 months (range 9 to 144). Overall, 17 (81%) of the 21 hospital survivors have remained free of major adverse events (recurrence of endocarditis, need for reoperation or death). The results of our study suggest that homograft aortic root replacement should be considered favorably in the treatment of patients with aortic prosthetic valve endocarditis and root abscesses.
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Elkins RC, Steinberg JB, Razook JD, Ward KE, Overholt ED, Thompson WM. Correction of truncus arteriosus with truncal valvar stenosis or insufficiency using two homografts. Ann Thorac Surg 1990; 50:728-33. [PMID: 2241332 DOI: 10.1016/0003-4975(90)90671-r] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Surgical correction of truncus arteriosus requires the creation of right ventricular to pulmonary artery continuity and closure of the ventricular septal defect. A variety of conduits have been used including valved and nonvalved. Despite a significant incidence of truncal valvar stenosis and insufficiency, this valve has seldom been replaced. We present 4 cases of truncus arteriosus with truncal valvar stenosis or insufficiency that were repaired using two valved homografts: one to create the pulmonary outflow tract and the other to replace the abnormal truncal valve. Two of these patients are doing well after 4 months. Another child survived the operation and did well for 2 months when she died suddenly. The last child died 14 hours postoperatively from low cardiac output syndrome secondary to diabetic hypertrophic cardiomyopathy. When truncal valvar abnormalities are present, the primary repair of truncus arteriosus in an infant should include replacement of the truncal valve. Total correction can be successfully achieved using two valved homografts, resulting in long-term palliation and freedom from thromboembolic events and the use of anticoagulants.
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Affiliation(s)
- R C Elkins
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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