Homograft Aortic Replacement Research Articles

Modified Warden procedure using aortic homograft for superior vena caval translocation: Where is the evidence?

Partial anomalous pulmonary venous connection (PAPVC) occurs when at least one pulmonary vein drains into the right atrium or its tributaries rather than the left atrium, most commonly connecting with the superior vena cava (SVC). The Warden procedure involves transecting the SVC proximal to the uppermost connection of the pulmonary vein followed by proximal SVC reattachment to the right atrial appendage. However, descending thoracic aortic homograft replacement for SVC translocation has recently been introduced as a modified technique. This commentary aims to discuss the recent study by Said et al. who reported their experiences with six PAPVC cases undergoing a modified Warden procedure using thoracic aortic homograft SVC translocation. A comprehensive literature search was performed using multiple electronic databases to collate the relevant research evidence. The Warden procedure is associated with a 10% incidence of SVC obstruction with many requiring reintervention. Meanwhile, using the aortic homograft for SVC translocation, Said et al. observed no SVC obstructions. In addition, this modified technique does not require anticoagulation and has demonstrated an improvement in long-term SVC patency. Nevertheless, it can be considered an expensive procedure. Moreover, since the thoracic aortic homograft utilized is biological tissue, only long-term follow-up will determine whether calcification and graft degeneration is an issue. It can be concluded that the modified Warden procedure is a safe and effective method to reconstruct the systemic venous drainage into the right atrium when a direct anastomosis under tension might be prone to re-stenosis.

Repair of aortoesophageal fistula with homograft aortic replacement and primary esophageal closure

ObjectivesThe presence of a fistula between the thoracic aorta and the esophagus is a rare and highly fatal condition. This study aimed to evaluate the outcomes of the surgical treatment of an aortoesophageal fistula (AEF). MethodsWe retrospectively reviewed patients with AEF who underwent surgery at our institution. ResultsBetween 2007 and 2018, a total of 10 patients who underwent surgery for AEF. The mean age was 63 ± 12 years, and 6 patients were men. Four patients had primary AEFs and 6 patients had secondary AEFs (3 graft replacements and 3 thoracic endovascular aortic repairs). The timing of AEF since graft replacement or thoracic endovascular aortic repairs was 21.6 ± 27 days. We performed aortic replacement with a prosthetic graft (4 patients) or a homograft (5 patients) and extra-anatomical bypass due to a previous aortic graft infection (1 patient). As a treatment of the esophagus, we conducted primary repair in 7 of 10 patients. The median lengths of hospital and intensive care unit stay were 59 days (range, 9-225 days) and 6.3 days (range, 1-87 days), respectively. Seven patients achieved oral feeding after a median 10.3 postoperative days (range, 7-78 postoperative days). Two of the 10 patients died of sepsis at 9 and 74 days postoperatively. ConclusionsThe strategy for patients with AEF should be individualized. Our surgical strategy for AEF, which includes simultaneous aortic graft replacement and primary repair of esophagus in the same operative field, is feasible and promising.

Long-term outcome of cryopreserved allograft for aortic valve replacement

ObjectiveThe most efficient surgical approach to severe aortic valve disease in the young adult is still debated: cryopreserved aortic allograft offers excellent hemodynamic and avoid anticoagulation, but long-term durability is influenced by structural valve deterioration (SVD). This study aimed to describe long-term results of aortic allografts and to identify factors influencing long-term durability. MethodsFrom January 1993 to August 2010, 210 patients underwent aortic allograft replacement via the free-hand subcoronary implantation technique (N = 55) or root replacement with coronary reimplantation (N = 155). Clinic and echocardiographic follow-up was updated to April 2016. ResultsOverall mortality and cardiac mortality occurred in 80 (38.1%) and 64 (30.5%) patients, respectively. Reoperation was required in 69 cases (32.8%), whereas SVD required reoperation in 57 cases (27.1%). No early endocarditis occurred, whereas late endocarditis occurred in 4 patients. The free-hand technique seems to be associated with improved left ventricular remodeling compared with the root-replacement technique, and smaller allograft size represents a predictor of reoperation independently on the surgical technique used. In the overall population, there were 44 women of childbearing age, and 37 patients remained pregnant during the follow-up of the study. No differences were found in the clinical outcomes among women who had children and who did not. ConclusionsCryopreserved allograft is a valid option, especially in complex infective endocarditis and in women of childbearing age. A careful choice of allograft size and implantation technique can reduce the risk of SVD.

Aortic homograft replacement in a patient with a porcelain aorta: A case report

Patients with a severely calcified (porcelain) aorta are often unsuitable candidates for cardiac surgery because of the high risk of neuroembolic complications from loose calcified particles.We describe a surgical technique in a patient with a porcelain aorta undergoing an aortic homograft replacement for infective endocarditis that used an oscillating saw and a surgical hand drill for suturing the calcified plates.

Heart transplantation in a patient with recurrent early extensive endocarditis

Active valvular endocarditis could be considered a contraindication to heart transplantation. Nevertheless, there have been some reports of success with this form of treatment, despite the characteristics of the infection and its aggressive nature. Here, we describe the case of a patient with acute bicuspid aortic valvular endocarditis caused by Staphylococcus aureus and with a periannular abscess. Cryopreserved aortic homograft replacement of the aortic root was initially carried out, in addition to debridement and reconstruction of the interventricular septum with a pericardial patch. Early recurrence occurred, however, with extensive tissue destruction, a periaortic abscess and involvement of multiple valves, associated with severe sepsis. In view of the failure of 'conventional' surgery, an emergency heart transplantation was decided on after discussing the case with the Spanish National Transplant Organization (ONT), because of the theoretical contraindication of transplantation in this case. Transplantation was finally carried out after a waiting period of 3 days, in emergency code conditions, and the postoperative course proved uneventful, with no reinfection during the follow-up period. The present case suggests that heart transplantation may be an alternative option in patients suffering aggressive endocarditis with extensive involvement of the heart structures.

Outcome of surgical repair of aorto-eosophageal fistulas with cryopreserved aortic allografts

Aorto-oesophageal fistula (AEF) is a rare but life-threatening disease with an underlying infective aetiology that can cause serious complications. This study investigated the clinical outcomes of patients with AEF who received in situ cryopreserved aortic allograft replacement. From August 2000 to February 2011, 11 patients with AEF received aortic allografts; 5 for primary AEF caused by ruptured aortic aneurysm and 6 for secondary AEF that comprised 4 cases following thoracic endovascular aortic repair (TEVAR) and 2 after open graft replacement of the thoracic aorta. As for results, 2 cases of primary AEF received TEVAR and then allograft replacement, one for graft infection and the other for bleeding. Three primary AEF cases received allografts directly. Six secondary AEF cases received staged (5) or simultaneous (1) oesophagectomy and allograft replacement. There were 3 in-hospital deaths (27%), 2 because of bleeding and one because of multisystem organ failure. Four patients completed oesophageal reconstruction. There were 2 late deaths, one due to aspiration pneumonia and one of unknown cause. In conclusion, surgical results for repair of AEF using cryopreserved aortic allograft were satisfactory considering preoperative critical condition, and this type of allograft appears to be an ideal graft of choice.

First successful transapical aortic valve implantation after aortic allograft replacement

First successful transapical aortic valve implantation after aortic allograft replacement

Redo in aortic homograft replacement: Transcatheter aortic valve as a valid alternative to surgical replacement

CLINICAL SUMMARY A 48-year-old woman was referred to our hospital with symptoms of ingravescent severe dyspnea. Fifteen years earlier, she had undergone placement of a 21-mm aortic valve Bravo 400 stentless xenograft (Cryolife International, Atlanta, Ga). Four years later, she underwent a valve replacement with a 21-mm mechanical prosthesis (Carbomedics, Austin, Tex) for valve degeneration, and subsequently, she received a homograft for aortic valve endocarditis. The echocardiographic control, performed during the last 15 years, showed progressive calcific valve degeneration with a peak transvascular pressure gradient of 41 mm Hg and aortic valve area of 0.5 cm. Preoperative computed tomographic angiographic analysis showed diffuse aortic root

First successful transapical aortic valve implantation after aortic allograft replacement

First successful transapical aortic valve implantation after aortic allograft replacement

Report of a Case of Streptococcus agalactiae Mycotic Aneurysm and Review of the Literature

A unique case of mycotic aneurysm of the abdominal aorta caused by Streptococcus agalactiae in an afebrile patient presenting with abdominal pain is described. Although this bacterium is associated with a variety of infections in human beings, aortitis is uncommon. Chronic alcoholism and diabetes mellitus are the 2 major predisposing conditions for group B Streptococci infection and both were present in this case. The abdominal pain and elevated inflammatory markers in the absence of fever were elusive in presentation; however, the diagnosis of mycotic aneurysm was established by abdominal computed tomography scan. The patient was treated successfully by resection of the diseased aorta and aortic allograft replacement. Culture of the excised tissue grew Streptococcus agalactiae sensitive to penicillin G and (other commonly tested antibiotics) fluoroquinolones. A prolonged course of moxifloxacin (for 6 months) was administered due to the persistence of elevated inflammatory markers and was remarkably well tolerated. Sixteen months after stopping the antibiotics, the patient is doing well, and the control imaging studies are satisfactory.

Allograft replacement of the aortic root for acute extensive aortic valve endocarditis

Introduction: A consensus regarding the ideal graft material in presence of acute native or prosthetic aortic valve endocarditis is still missing. Aortic allograft replacement has been the policy in our institution. We are reporting on our experience.

Aortoesophageal fistula: value of in situ aortic allograft replacement.

The purpose of this report is to describe our experience in management of aortoesophageal fistulas (AEF) with special emphasis on the value of in situ aortic allograft replacement. Nine patients presenting with AEF were observed between May 1988 and April 2002. There were 4 men and 5 women with a mean age of 54.3 years (range, 32-77 years). Six patients presented secondary AEF after aortic repair. Two patients presented primary AEF after rupture of an atherosclerotic aneurysm into the esophagus. In the remaining patient, AEF was caused by swallowing a fishbone. In 6 cases involving true AEF with a direct communication between the aorta and esophagus, massive exsanguinating hematemesis occurred. It was usually preceded by minor sentinel bleeding. Two patients presented esophagoparaprosthetic fistula (EPPF). One patient presented primary AEF that was contained by a large thrombus in the communication. The clinical picture in these 3 patients involved severe sepsis without hemorrhage. Two patients died as a result of massive hemorrhage before assessment and surgical treatment could be undertaken. One 77-year-old woman presenting EPPF refused to undergo surgery and died because of infection. The remaining 6 patients underwent surgical treatment with various outcomes. One man died during thoracotomy caused by exsanguinating hemorrhage. One woman presenting EPPF was treated by exclusion followed by ascending aorta to abdominal aorta bypass grafting, removal of the prosthesis, esophageal exclusion, and directed esophageal fistula. She died of infection. The other 4 patients were treated by in situ aortic allograft replacement. The damaged esophagus was repaired by using the Thal technique in 1 patient. In the remaining 3 cases subtotal esophagectomy was performed in association with cervical esophagostomy, ligation of the abdominal esophagus, gastrostomy, and jejunostomy. One patient died of sepsis during the first 24 hours after the operation. The other 3 patients underwent secondary esophagoplasty and survived with no further sign of infection. Mean duration of follow-up in the survivor group was 53 months (range, 15-95 months). Overall 6 patients, including 3 that did not undergo surgical treatment, died and 3 patients survived. Our experience confirms that AEF is a rare but catastrophic disorder. In situ allograft replacement usually in association with subtotal esophagectomy appears to be an excellent salvage modality whenever emergency surgery is feasible.

Immune response after cryopreserved aortic allograft replacement for major vascular infection

Immune response after cryopreserved aortic allograft replacement for major vascular infection

The distinguished service award for the Society for Vascular Surgery, 2000: D. Emerick Szilagyi, MD

Dr Szilagyi has been a giant in vascular surgery for more than a half century. He was born in 1910 in Nagykaroly, Hungary, and completed a classic undergraduate education in Europe, where he attended Calvinist College in Klausenburg and the University of Debrecen, both in Hungary. This was followed by studies at the Sorbonne in Paris. In spring of 1931, Dr Szilagyi and his brother immigrated to Detroit to join their mother. In the fall of 1931, he entered the University of Michigan Medical School, from where he graduated cum laude in 1935. Between 1935 and 1937, Dr Szilagyi was a surgical intern at the University of Michigan, which was a 2-year rotating internship. At the conclusion of these 2 years, he became a teaching assistant in the Department of Pathology, where he worked for Dr Carl Weller in anatomic pathology. In 1939, he became an assistant resident in surgery at Henry Ford Hospital in a program headed by Dr Roy D. McClure, one of Dr Halsted's famous “chosen 17.” Between 1942 and 1945, Dr Szilagyi worked as Medical Director for the Ford Rubber Plantation in the Amazon Valley of Brazil. During his 2½-year tour of duty, Dr Szilagyi performed a wide variety of surgical procedures; he stated that he operated on all organs, except the brain and heart. In 1945, he returned to Detroit, where he spent 1 year as anassistant surgeon and 1 year as a chief surgical resident. He then served as chief of one of the two surgical divisions of the Department of General Surgery until 1966, when he became chairman of the Department of Surgery at Henry Ford Hospital. He was active in surgical practice until 1984, when he decided to devote all his energies to his work as an editor for theJournal of Vascular Surgery Among Dr Szilagyi's achievements was the early use of the aortic homograft replacement for abdominal aortic aneurysm. He also established one of the first registries for vascular surgery patients. The medial approach to the popliteal artery was also one of his innovations. Of the more than 180 articles published, there are three that are his most important. The first one, published in 1957 in the Archives of Surgery , states that there were high rates of long-term failures with homografts, and this technique should not be continued. The second, published in 1966 in the Annals of Surgery, outlines the contributions of abdominal aortic aneurysm resections to the prolongation of life. This article has been officially recognized as a citation classic and is one of the most commonly referenced articles in vascular surgery. His 1973 paper, published in the Annals of Surgery , on the long-term results of lower extremity vein bypasses is a landmark in terms of demonstrating the technique for careful and long-term follow-up of lower extremity reconstruction. This paper has served as a guide to succeeding generations of vascular surgeons, by demonstrating the importance of meticulous long-term follow-up and analysis of any surgical reconstructive procedure. Dr Szilagyi's accomplishments have been recognized by serving as president of various surgical organizations. These organizations include the Central Surgical Association; the Western Surgical Association; the Midwestern Vascular Surgery Society; the American Association for Vascular Surgery, a Chapter of the International Society for Cardiovascular Surgery; and the Society for Vascular Surgery. Dr Szilagyi's most enduring contribution, in my estimation, is the work he did as the first editor of the Journal of Vascular Surgery. The rigorousness with which he evaluated the manuscripts and the care he gave to his editorial work were significant factors in the Journal of Vascular Surgery becoming one of the preeminent surgical journals and the best vascular surgery journal in the world today. Many of us will recall getting these almost encyclopedic letters from Dr Szilagyi requesting clarification and changes to our manuscripts. When all was said and done, these papers were significantly improved by making the changes required by Dr Szilagyi. His ability to critically look at surgical results is without compare. For his half century–long contributions to vascular surgery and in particular, the Society for Vascular Surgery, I am proud to present Dr D. Emerick Szilagyi the Society for Vascular Surgery Distinguished Service Award.

Mediastinal false aneurysm after thoracic aortic surgery

Background. Postoperative mediastinal false aneurysm is associated with a substantial morbidity and mortality. Surgical treatment is mandatory, although the individual approach varies according to the type of pathologic process, infection status, and site of origin of the aneurysm. Methods. Between April 1993 and February 1999, we treated 10 patients, aged 25 to 73 years, with anastomotic mediastinal false aneurysm originating from the proximal thoracic aorta. Nine had undergone prior operations on the ascending aorta (7, type A dissection repair; 1, aortitis; 1, root abscess) with a Dacron conduit (n = 5) or valved conduit (n = 4). The last patient had undergone valve replacement for excavating aortic root sepsis. False aneurysms were detected from 2 to 70 months after the most recent operation. Three patients had positive tissue cultures. The surgical procedure was direct suture repair of the disrupted anastomosis in 5, root or ascending aortic replacement with an aortic homograft in 4, and Dacron graft interposition in 1. Hypothermic low-flow perfusion with or without circulatory arrest was used in all patients. Results. There was one hospital death caused by staphylococcal mediastinitis. A false aneurysm recurred after direct suture repair in 2 patients with underlying type A dissection or aortitis. This resulted in one late death. One patient experienced a neurologic event during removal of an infected vascular graft. All 8 surviving patients are alive and well after a mean follow-up of 2 years. Three patients with mycotic false aneurysms remain free from infection after aortic homograft replacement. Conclusions. Mediastinal false aneurysms are surgically taxing. Low-flow hypothermic perfusion with or without circulatory arrest allows safe reentry. Radical surgery provides a satisfactory outcome in infected patients. Local repair of suture dehiscence in pathologic tissues may predispose to recurrence. We suspect that excessive use of formalin in gelatin-resorcin-formol glue may predispose to tissue necrosis.

Patient outcome and valve performance following a second aortic valve homograft replacement.

Homograft valves offer many advantages; however, there is concern about their use in second aortic valve replacement because of the complexity of the procedure and the possibility of accelerated degeneration. One hundred and forty-four patients underwent a second aortic homograft replacement between 1973 and 1997 (mean follow-up 6.5+/-5 years, range 1 to 20 years). Eighty-three were male, and 61 were female, aged 17 to 77 years, mean 49.0 years. All patients had undergone previous aortic valve replacement with a homograft. The indication for reoperation was aortic regurgitation in 75 patients (52.1%), aortic stenosis in 28 (19.4%), and mixed aortic valve disease in 41 (28.5%). Root replacement was performed in 54 patients (38%) and subcoronary in 90 (62.5%). Early mortality was 3.4%. The actuarial survival rate was 93% and 82% at 5 and 10 years, respectively. Freedom from tissue degeneration was 96% and 80% at 5 and 10 years, respectively, and freedom from reoperation was 97% and 82% at 5 and 10 years, respectively. This study shows that a second aortic valve homograft replacement results in good early and long-term survival. Accelerated degeneration does not occur. Left ventricular performance is improved, and earlier surgery could further improve outcome, indicating that an aortic homograft is a safe, durable option for patients requiring a second aortic valve replacement.

Patient Outcome and Valve Performance Following a Second Aortic Valve Homograft Replacement

Background —Homograft valves offer many advantages; however, there is concern about their use in second aortic valve replacement because of the complexity of the procedure and the possibility of accelerated degeneration. Methods and Results —One hundred and forty-four patients underwent a second aortic homograft replacement between 1973 and 1997 (mean follow-up 6.5±5 years, range 1 to 20 years). Eighty-three were male, and 61 were female, aged 17 to 77 years, mean 49.0 years. All patients had undergone previous aortic valve replacement with a homograft. The indication for reoperation was aortic regurgitation in 75 patients (52.1%), aortic stenosis in 28 (19.4%), and mixed aortic valve disease in 41 (28.5%). Root replacement was performed in 54 patients (38%) and subcoronary in 90 (62.5%). Early mortality was 3.4%. The actuarial survival rate was 93% and 82% at 5 and 10 years, respectively. Freedom from tissue degeneration was 96% and 80% at 5 and 10 years, respectively, and freedom from reoperation was 97% and 82% at 5 and 10 years, respectively. Conclusions —This study shows that a second aortic valve homograft replacement results in good early and long-term survival. Accelerated degeneration does not occur. Left ventricular performance is improved, and earlier surgery could further improve outcome, indicating that an aortic homograft is a safe, durable option for patients requiring a second aortic valve replacement.

Cryopreserved Aortic Homograft Replacement in a Patient With Takayasu's Arteritis

A patient with severe long-standing Takayasu's arteritis underwent successful replacement of the aortic root and ascending aorta with a cryopreserved aortic homograft. Her postoperative course was uneventful and echocardiography demonstrated evidence of neither aortic regurgitation nor graft detachment more than 2 years after the operation. Magnetic resonance image demonstrated no signs of graft enlargement.

Comparison of Ross procedures and aortic valve allografts in children

Background. The Ross procedure is useful, but at times an allograft valve is the only alternative to a mechanical aortic prosthesis. Since 1994 the Ross procedure or aortic allograft replacement has been used exclusively for aortic valve replacement at our institution. Methods. Demographic, clinical, and echocardiographic data of 23 consecutive Ross and 8 allograft patients were compared. Results. Groups were similar in age and weight. The Ross group had fewer prior operations. There were no deaths or major complications in either group. The Ross group had no late complications of the autograft but 1 reoperation for pulmonary allograft stenosis. In the allograft group there was one reoperation for allograft insufficiency. Echocardiography was performed 2 to 11 days (mean, 4.3 days) after operation and 1 to 28 months (mean, 10.2 months) later. In the Ross group left ventricular wall thickness (mm) decreased from 11.0 ± 2.3 to 7.8 ± 1.7 ( p < 0.0001), and left ventricular outflow tract maximal systolic velocity (m/sec) decreased from 1.9 ± 0.6 to 1.4 ± 0.4 ( p = 0.0001). In the allograft group left ventricular wall thickness (mm) decreased from 10.5 ± 2.6 to 9.0 ± 2.6 (not significant), and left ventricular outflow tract maximal systolic velocity (m/sec) increased from 1.5 ± 0.9 to 1.9 ± 0.7 (not significant). Conclusions. The Ross procedure results in significant improvement in left ventricular wall thickness and outflow tract velocity not seen in allograft aortic valve replacements. The Ross procedure remains the preferred operation for children requiring aortic valve replacement.

Cryopreserved aortic allograft replacement of infected prosthetic grafts in man: processing and clinical results

Cryopreserved aortic allograft replacement of infected prosthetic grafts in man: processing and clinical results