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Ann Thorac Surg 2005;79:645
© 2005 The Society of Thoracic Surgeons

INVITED COMMENTARY

Roger J.F. Baskett, MD

Division of Cardiac Surgery, Maritime Heart Centre, Rm 2269, 2nd Fl, 1796 Summer St, Halifax, NS, Canada B3H 3A7

The study by Hooper and associates is another contribution to the understanding of the response to allograft implantation and their mode of failure in children. This group previously demonstrated a dramatic early rise in panel reactive antibodies in children who received cryopreserved allografts. This work is part of a growing body of evidence that allograft valved conduits elicit a donor specific immune response that is particularly marked in children.

Furthermore there is now evidence that this response may affect the longevity of the allograft in children.

In the current study, the group from Salt Lake City has demonstrated that the early antibody response seen in young children often persists for years after implantation, although at a much diminished level in most cases. This suggests a persistence of antigenic stimulus or more likely immune memory, or both. However they have not demonstrated that the persistence of these antibodies has any effect on allograft function or longevity. However the implication can not be ignored.

At present the cryopreserved allograft remains the best option for young children requiring valved conduits. However, the mechanism of their failure is not fully understood. Clearly there is an immune response to these allografts, and it is increasingly evident that this response is at least partly responsible for their failure.

Despite this and other recent studies we still do not fully understand the mechanism of allograft valve failure. We will only be able to target interventions in an intelligent manner when we do fully understand it. There are a number of important areas under investigation, including modifying the allograft and altering host immune responses. Both the understanding of allograft failure and more importantly the assessment of any new interventions will require multicenter collaboration. This small but important study highlights the need for multicenter collaboration to answer the important questions about allograft failure.





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