Pulmonary homograft: should it be used in the aortic position?

Homograft aortic valve replacement--the experience of one unit

BACKGROUND

Homograft valves offer advantages including avoidance of anticoagulation and less susceptibility to infection especially in the setting of endocarditis. However, there is concern about their durability and possible accelerated degeneration particularly in cases of second time replacement with homografts.

AIM

This study aimed to evaluate the pattern of homograft failure and the quality of life in patients after homograft implantation.

METHODS

Between 1990 and 1998, 58 patients underwent aortic valve replacement with a homograft (aortic homograft = 47, pulmonary homograft = 11). Evaluation was based on clinical and echocardiographic examination, patient questionnaires and explanted valve pathology. Survival and freedom from cardiac related death were expressed by actuarial methods.

RESULTS

Follow up ranged from 1 to 10 years (mean 5.5 years). Analysis of questionnaires revealed 60% of respondents to be in good performance status and 20% in moderate and 20% in poor performance status groups. Eleven patients (18.9%) required subsequent redo valve replacement after initial homograft insertion (pulmonary = 6, aortic = 5) due to either valve dehiscence (n=4) or valve degeneration (n=7). The mean interval of re-replacement was 5.4 years.

CONCLUSIONS

Pulmonary homografts have a high failure rate in the aortic position. Overall subjective and clinical improvement after surgery is less than expected for a "physiological" device. In the setting of low availability of homografts the use of off-the-shelf devices such as stentless xenografts may be preferable in most cardiac surgical units in the current era.

Aortic Homograft: A Suitable Substitute for Aortic Valve Replacement

BACKGROUND

The aim of our study is to assess the results of aortic valve replacement with the aortic homograft.

METHODS

From January 1994 through September 2003, 154 patients with aortic valve disease (rheumatic = 118, nonrheumatic = 36), and a mean age of 28.8 +/- 18.2 years, underwent aortic valve replacement with an aortic homograft by the scalloped subcoronary (n = 110) or root replacement (n = 38) technique, or as a valved homograft conduit (n = 6). Associated procedures included mitral valve repair (n=30), open mitral commissurotomy (n = 22), tricuspid valve repair (n = 8), coronary artery bypass grafting (n = 6), and atrial septal defect closure (n = 1).

RESULTS

Early mortality was 7.8% (12 patients). Mean follow-up was 62 +/- 33.4 months (4 to 127 months; median, 68.5 months). One hundred and twenty-four survivors (87.3%) had no or trivial to mild aortic regurgitation. A total of six patients required reoperation for homograft dysfunction alone (n = 4), infective endocarditis (n = 1), or failure of mitral valve repair (n = 1). There were four late deaths. Actuarial and reoperation-free survival at the median follow-up were 92.2 +/- 2.2% and 95.8 +/- 1.9%, respectively. Freedom from significant aortic stenosis or regurgitation was 86.1 +/- 3.2%.

CONCLUSIONS

Aortic valve replacement with an aortic homograft can be performed with acceptable early and late mortality and provides satisfactory midterm results. We did not note any difference in homograft dysfunction and reoperation with the use of either scalloped subcoronary or root replacement technique.