The Valve-in-Valve Operation for Aortic Homograft Dysfunction: A Better Option

Abstract

Reoperations on dysfunctional aortic homografts often require root reconstruction with coronary reanastomosis. This is associated with substantial perioperative morbidity and mortality. Resecting compromised aortic homograft valve leaflets and seating a new valve within the homograft annulus avoids root reconstruction and is a viable alternative. We retrospectively evaluated 50 patients undergoing reoperations on dysfunctional homografts between 1999 and 2011. Outcomes were compared between valve-in-valve (ViV) and aortic valve-prosthetic conduit (AVR-C) procedures. Twenty-eight patients underwent ViV, and 22 had AVR-C. Groups were similar in age, sex, and incidence of endocarditis and renal failure. Median time between homograft and index procedure was 8.5 years for AVR-C and 8 years for ViV patients (p=0.93). Patients undergoing AVR-C had longer cardiopulmonary bypass (282 versus 151 minutes; p<0.001) and cross-clamp (207 versus 106 minutes; p<0.001) times and received significantly more intraoperative red blood cell transfusions than ViV patients (36.4% versus 7.1%; p=0.014). Patients undergoing ViV had shorter intensive care unit stays (47 hours versus 67 hours for AVR-C; p=0.049) and fewer postoperative red blood cell transfusions (21.4% versus 54.5%; p=0.020). There were trends toward shorter ventilation times for ViV patients (6 hours versus 11 hours for AVR-C; p=0.077), shorter postoperative length of stay (7 days versus 9 days; p=0.092), and fewer readmissions (3.6% versus 19.0%; p 0.073). One operative mortality occurred in the AVR-C group. The strategy of replacing aortic valve leaflets in a failed calcified homograft, with a valve seated inside the annulus, is a safe alternative to root reconstruction. Preserving root architecture and coronary buttons facilitates shorter cardiopulmonary bypass and cross-clamp times, and directly impacts transfusions, intensive care unit time, hospital stay, and readmission rates.