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Ann Thorac Surg 1999;67:1846-1848
© 1999 The Society of Thoracic Surgeons

Aortic allografts and pulmonary autografts for replacement of the aortic valve and aortic root

^a The Heart Center, Missouri Baptist Medical Center, St. Louis, Missouri, USA

Address reprint requests to Dr Kouchoukos, 3009 N. Ballas Rd, Suite 266C, St. Louis, MO 63131

Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.

	Abstract

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Background. Extensive experience has accumulated with the use of aortic and pulmonary autografts for replacement of the aortic valve and the aortic root. Three general techniques for insertion have been used: subcoronary (free-hand) valve implantation, mini- or inclusion-root implantation, and aortic root replacement. Thirty-day mortality for elective operations with all of these techniques has not exceeded 5%. Thromboembolic episodes have been rare, and endocarditis has occurred infrequently. Early hemodynamic performance has been excellent, without significant gradients or valve regurgitation in the majority of patients.

Methods and Results. Progressive aortic regurgitation has been observed with continued follow-up, and is the most important complication of both types of valves. Leaflet failure and technical problems are the major causes of reoperation for patients receiving aortic allografts. There is some evidence to suggest that the prevalence of these complications is lower with the root replacement technique than with the intraaortic implantation methods.

Conclusions. Reoperation for regurgitation of the neo-aortic valve is the major complication of the pulmonary autograft procedure. The incidence of reoperation appears to be lowest with the root replacement technique. Certain conditions (acute rheumatic fever, juvenile rheumatoid arthritis, systemic lupus, ankylosing spondylitis, Libman-Sachs endocarditis, and possibly a dilated aortic root) may be contraindications to the use of a pulmonary autograft. Reoperation on the pulmonary allograft that is used to replace the autograft may be necessary in up to 20% of patients at 20 years.

	Introduction

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Over the past 30 years, extensive experience has accumulated with the use of aortic allografts and pulmonary autografts for replacement of the aortic valve and the aortic root. Both of these grafts were first implanted into humans in the late 1960s. Aortic allografts were used in substantial numbers in the late 1960s and early 1970s, and then less frequently as other valve substitutes, such as porcine bioprostheses, became available. With the availability of commercially prepared allografts in the late 1980s, there has been an increase in the use of these valves. Substantial experience with the pulmonary autograft (Ross procedure) has accumulated only in the last 5 to 6 years, again related to the availability of commercially prepared pulmonary allografts to replace the right ventricular outflow tract. Three general techniques for insertion of both types of grafts have been used: subcoronary (free-hand) valve implantation, mini- or inclusion root implantation, and aortic root replacement. There has been a trend in many centers towards exclusive use of the root replacement technique with both types of grafts [1, 2].

	Mortality

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Early mortality has not exceeded 3% with either procedure in experienced centers [1, 3–5]. The mean age of the patients in these series was under 50 years. Early mortality has been higher in subsets of patients undergoing aortic valve or root replacement with aortic allografts for endocarditis or acute aortic dissection. Data from the Ross Procedure International Registry, which contains information on over 3100 patients, indicate a 30-day mortality of 4.8% for 1656 patients available for analysis [2]. The mean age at operation was 29.6 years. Among these patients, myocardial failure and bleeding were the most common modes of death.

Among patients receiving aortic allografts in whom extended follow-up is available, 8- to 10-year survival has ranged between 70% and 85% [1, 5, 6]. For patients receiving pulmonary autografts, survival in three series of patients with more than 5 years of follow-up has ranged from 97% to 87% at 7 to 8 years [3, 4, 7].

	Morbidity

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Thromboembolic episodes have been rare and endocarditis has occurred infrequently with both types of grafts [1, 3–5, 6, 8]. In the pioneering series of pulmonary autografts of Donald Ross, which began in 1967 and included 131 hospital survivors who were followed for a minimum of 8 and a maximum of 26 years (with a mean of 20), endocarditis occurred in 12 patients (9.2%: 3 on the autograft, 4 on the pulmonary allograft, and 5 on other valves); thromboembolism was seen in 16 patients (12.2%: 11 systemic and 5 pulmonary); and documented arrhythmias in 30 patients (23%: atrial fibrillation in 20, complete heart block in 5, ventricular fibrillation in 2, and other in 3) [9]. The mean age at operation of the patients in this series was 32 years.

Progressive aortic valve regurgitation has been observed with continued follow-up, and is the most important complication with both types of grafts. Leaflet failure and technical problems are the major causes of reoperation for recipients of aortic allografts. With cryopreserved grafts, freedom from reoperation at 8 years is 85% to 90%, [1, 5, 6] and at 15 years is 69% [10]. With the Ross procedure, malfunction of the pulmonary allograft in the right ventricular outflow tract is a complication that also requires reoperation. In the pioneering series of Ross, freedom from reoperation for any cause was 76% at 10 years and 62% at 20 years [9]. Freedom from reoperation on the autograft was 88% at 10 years and 75% at 20 years. For the pulmonary allograft, these rates were 89% and 80%, respectively. In the more contemporary series, freedom from reoperations at 8 years ranges from 90% to 82% for failure of the autograft, and from 94% to 88% for failure of the allograft [3, 4]. The presence of an ascending aortic aneurysm is a risk factor for the development of more than mild neo-aortic valve regurgitation and the need for reoperation on the autograft [3].

	Contraindications

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With increasing experience, contraindications to the use of aortic allografts and pulmonary autografts have emerged, and these are summarized in Table 1. There are relatively few contraindications to use of aortic allografts, and these relate primarily to the presence of a dilated aortic annulus, severe left ventricular dysfunction, or extensive coronary artery disease. Use of a pulmonary autograft is contraindicated in patients with severely impaired ventricular function, extensive coronary artery disease, multiple valve disease requiring replacement, Marfan syndrome, and in patients with a number of immune-mediated diseases, where a high incidence of failure of the autograft valve has been observed (Table 1). Although tailoring of the aortic root and correction of aortic regurgitation due to dilation of the aortic root by reduction annuloplasty has been reported, long-term results with these procedures are not available [11–13]. Thus, a dilated aortic annulus (> 30 mm), particularly when associated with an aneurysm of the ascending aorta, may represent a contraindication to use of a pulmonary autograft.

	Indications

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	References

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1. O’Brien M.F., Finney R.S., Stafford E.G., et al. Root replacement for all allograft aortic valves: preferred technique or too radical?. Ann Thorac Surg 1995;60(Suppl):87-91.
2. Oury J.H., Hiro S.P., Maxwell J.M., Lamberti J.J., Duran C.M.G. The Ross Procedure: current registry results. Ann Thorac Surg 1998;66(Suppl):S162-S165.
3. Elkins R.C., Knott-Craig C.J., Ward K.E., Lane M.M. The Ross operation in children: 10-year experience. Ann Thorac Surg 1998;65:496-502.[Abstract/Free Full Text]
4. Kouchoukos N.T., Murphy S.F., Nickerson N.J., et al. Long-term follow-up after aortic root replacement with a pulmonary autograft. Circulation 1997;961(Suppl I):430.
5. Doty J.R., Salazar J.D., Liddicoat J.R., et al. Aortic valve replacement with cryopreserved aortic allograft: ten-year experience. J Thorac Cardiovasc Surg 1998;115:371-380.[Abstract/Free Full Text]
6. Kirklin J.K., Smith D., Novick W., et al. Long-term function of cryopreserved aortic homografts. J Thorac Cardiovasc Surg 1993;106:154-166.[Abstract]
7. Hokken R.B., Cromme-Dijkhuis A.H., Bogers A.J., et al. Clinical outcome and left ventricular function after pulmonary autograft implantation in children. Ann Thorac Surg 1997;63:1713-1717.[Abstract/Free Full Text]
8. Kouchoukos N.T., Davila-Roman V.G., Spray T.L., et al. Replacement of the aortic root with a pulmonary autograft in children and young adults with aortic valve disease. N Engl J Med 1994;330:1-6.[Abstract/Free Full Text]
9. Chambers J.C., Somerville J., Stone S., Ross D.N. Pulmonary autograft procedure for aortic valve disease. Circulation 1997;96:2206-2214.[Abstract/Free Full Text]
10. O’Brien M.F., Stafford E.G., Gardner M.A., et al. Allograft aortic valve replacement: long-term follow-up. Ann Thorac Surg 1995;60(Suppl):65-70.[Free Full Text]
11. David T.E., Omran A., Webb G., et al. Geometric mismatch of the aortic and pulmonary roots causes aortic insufficiency after the Ross procedure. J Thorac Cardiovasc Surg 1996;112:1231-1239.[Abstract/Free Full Text]
12. Durham L.A., desJardins S.E., Mosca R.S., Bove E.L. Ross procedure with aortic root tailoring for aortic valve replacement in the pediatric population. Ann Thorac Surg 1997;64:482-486.[Abstract/Free Full Text]
13. Elkins R.C., Lane M.M., McCue C. Pulmonary autograft reoperation: incidence and management. Ann Thorac Surg 1996;62:450-455.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Nicholas T. Kouchoukos Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kouchoukos, N. T. Search for Related Content PubMed PubMed Citation Articles by Kouchoukos, N. T.