Ann Thorac Surg 2005;80:838
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Wei-Guo Ma, MD
Department of Cardiovascular Surgery, Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, 167 Northern Lishi Rd, Beijing, 100037, China
(Email: wgma{at}yahoo.com).
Aortic valve replacement with homograft (HAVR) has been evolving for four decades since its first introduction by Barrat-Boyes and Ross in 1962. The advantages of aortic homograft lie in its satisfactory hemodynamics, no need for anticoagulation, and low risk of thromboembolism and endocarditis. The work presented by Talwar and colleagues [1] has achieved excellent clinical outcomes. There was no early valve incompetence necessitating intervention. The 10-year actuarial freedom from valve dysfunction was as high as 94% although the patients were comparatively younger. This was probably attributed to good surgical technique and optimal homograft cryopreservation. Surprisingly, no thromboembolism was noted in the whole series. This report will certainly promote more interest and efforts in the field of homograft valve surgery.
The disadvantages of HAVR are the risk of early valve failure due to technical error, limited durability and availability. With easier availability, mature surgical techniques and improved long-term results, mechanical and tissue valve prostheses still remain the choice of substitutes in aortic valve replacement. The authors compared their results with other reports in terms of freedom from reoperation and survival. Caution should be taken to compare the clinical outcomes of aortic substitutes from different studies due to patient heterogeneity and different study periods. Age-adjusted comparison of freedom from valve dysfunction and patient survival from different studies is needed. The authors reported 5 occurrences of endocarditis with a linearized rate of 0.67% patient-year, which was higher than other reports. This could probably result from inadequate antibiotic pretreatment of the homograft.
While the authors argue pulmonary autograft is not recommended for young rheumatic aortic valve patients, particularly with mitral valve involvement, Ross procedure could be performed in young aortic valve patients if their mitral and pulmonary valves are intact. Despite the debates regarding the operative techniques, HAVR should be tailored to individual patients so as to choose the scalloped subcoronary or root replacement technique. In view of the long-term prognosis, the surgeon should use, if possible, the subcoronary replacement technique, which makes the reoperation much easier. Root replacement is only indicated in patients with aortic root involvement. The best way to compare the long-term results of these two techniques is to carry out a randomized clinical trial, which is ethically difficult.
Talwar and colleagues are to be congratulated for presenting a nice paper in HAVR. It is more applicable in areas where heart valve prostheses are not easily available or anticoagulation is contraindicated.
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References
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- Talwar S, Mohapatra R, Saxena A, Singh R, Sampath Kumar A. Aortic homografta suitable substitute for aortic valve replacement. Ann Thorac Surg 2005;80:832-838.[Abstract/Free Full Text]
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