Surgery on the Failing Aortic Homograft: A Changing Paradigm?

Abstract

Since the establishment of the Sydney Heart Valve Bank at St Vincent's Hospital in 1991, there have been over 150 aortic homograft implants. Homografts account for <1% of aortic valve replacements (AVR). Currently, the main indication is acute infective endocarditis with perivalvular abscess. Over a decade ago, a significant number of homografts were implanted in young patients with congenital aortic valve disease, aiming to avoid anticoagulation and potentially provide a prosthesis with good durability. Unfortunately, homografts develop severe calcification and structural deterioration (or endocarditis) requiring redo cardiac surgery. Re-operation can be technically demanding. This presentation reviewed redo aortic valve surgery in aortic homografts. Eleven patients were identified: eight redo Bentall operations and three redo AVR with sutureless valves. The redo Bentalls operations were performed until 2016, and patients were almost 100 minutes longer on cardiopulmonary bypass and had 1 hour longer cross clamp time than the sutureless valves. There were two deaths, both from the Bentalls group. Sutureless AVR patients had a shorter intensive care unit and overall hospital length of stay. Sutureless valve implant was more likely in the current era (2017 onwards). With the development of sutureless valves, surgeons now can potentially avoid root replacement surgery for the calcified homograft. Transcatheter aortic valve implantation for the degenerated aortic homograft may be an option in the future; however, due to the high concomitant procedure rate (coronary or mitral disease, endocarditis) in this ‘young’ group, no patients were suitable.