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The Annals of Thoracic Surgery, Vol 57, 1501-1505, Copyright © 1994 by The Society of Thoracic Surgeons
CJ Knott-Craig, RC Elkins, PL Stelzer, JD Randolph, C McCue, PA Wright and MM Lane
Homograft replacement of the aortic valve has inherent advantages for the
patient in terms of decreased incidence of thromboembolism, endocarditis,
and anticoagulation-related complications. Limitations in its use stem from
a significant incidence of postoperative aortic regurgitation, related to
difficulty with consistent commissural and sinotubular geometry when
inserted in the subcoronary position. To minimize this complication, we
used a homograft as a functional unit in 71 patients between 1986 and May
1993, either as a root replacement (n = 58) or as an intraaortic inclusion
cylinder (n = 13). There were 4 pulmonary and 67 aortic homografts. Mean
age of the 16 female and 55 male patients was 42 +/- 19 years (range, 0.6
to 84 years). Thirty patients had predominantly aortic regurgitation, 19
aortic stenosis, 18 mixed aortic valve disease, and 4 primary aneurysmal
disease. Eighteen (25.4%) had infective endocarditis. Thirty-five patients
(49%) had a previous operation on the aortic valve. Hospital mortality was
14.1% (10/71), 0% for inclusion cylinders and 17.2% (10/58) for root
replacements (p = not significant). Recent follow-up was obtained in all
hospital survivors. Mean follow-up period was 35 months (range, 1 to 81
months). There were six late deaths, 1/13 for inclusion cylinders and 5/48
for root replacements. Actuarial survival at 5 years was 74.9% +/- 5.6%.
Reoperation was required in 3 patients (all with root replacements), 1 for
postoperative endocarditis, 1 for left coronary ostial obstruction, and 1
for late onset of aortic dilatation and regurgitation (pulmonary homograft
used as a root replacement). Two patients currently have asymptomatic
greater than 2/4 aortic regurgitation. Freedom from significant aortic
regurgitation was 88% +/- 7% at 6-year follow-up. More consistent
maintenance of the sinotubular and commissural geometry of the aortic
homograft may be achieved with the root replacement or the inclusion
cylinder techniques. This may reduce the incidence of postoperative aortic
regurgitation and further benefit the patient by reducing the need for
reoperation in the future.
ARTICLES
Homograft replacement of the aortic valve and root as a functional unit
Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190.
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