Homograft Aortic Root Replacement Research Articles

Homograft Aortic Root Replacement for Destructive Prosthetic Valve Endocarditis: Results in the Current Era.

Background: Destructive aortic prosthetic valve endocarditis portends a high morbidity and mortality, and requires complex high-risk surgery. Homograft root replacement is the most radical and biocompatible operation and, thus, the preferred option. Methods: A retrospective analysis was conducted on 61 consecutive patients who underwent a cardiac reoperation comprising homograft aortic root replacement since 2010. The probabilities of survival were calculated with the Kaplan-Meier method, whereas multivariable regression served to outline the predictors of adverse events. The endpoints were operative/late death, perioperative low cardiac output and renal failure, and reoperations. Results: The operative (cumulative hospital and 30-day) mortality was 13%. The baseline aspartate transaminase (AST) and associated mitral procedures were predictive of operative death (p = 0.048, OR [95% CIs] = 1.03 [1-1.06]) and perioperative low cardiac output, respectively (p = 0.04, OR [95% CIs] = 21.3 [2.7-168.9] for valve replacement). The latter occurred in 12 (20%) patients, despite a normal ejection fraction. Survival estimates (±SE) at 3 months, 6 months, 1 year, and 3 years after surgery were 86.3 ± 4.7%, 82.0 ± 4.9%, 75.2 ± 5.6, and 70.0 ± 6.3%, respectively. Survival was significantly lower in the case of AST ≥ 40 IU/L (p = 0.04) and aortic cross-clamp time ≥ 180 min (p = 0.01), but not when excluding operative survivors. Five patients required early (two out of the five, within 3 months) or late (three out of the five) reoperation. Conclusions: Homograft aortic root replacement for destructive prosthetic valve endocarditis can currently be performed with a near 90% operative survival and reasonable 3-year mortality and reoperation rate. AST might serve to additionally stratify the operative risk.

Transcatheter aortic valve-in-valve implantation within stentless landing zones: Procedural insights from a single-center experience.

Valve-in-valve (VIV) transcatheter aortic valve implantation (TAVI) is a less invasive therapeutic option compared with redo surgical valve replacement for high-risk patients. Relative to procedures within stented surgical valves, VIV-TAVI within stentless valves is associated with a higher complication rate due to challenging underlying anatomy and absence of fluoroscopic landmarks. We share a single-center experience with VIV-TAVI in stentless valves, discussing our procedural insights and associated outcomes. Our institutional database was queried, and 25 patients who had undergone VIV-TAVI within a stentless bioprosthesis, homograft, or valve-sparing aortic root replacement between 2013 and 2022 were found. Outcome endpoints were based on the Valve Academic Research Consortium-3 criteria. The mean age of the cohort was 69.5 ± 13.6 years. VIV implantation was performed within a homograft in 11 patients, a stentless bioprothesis in 10 patients, and a valve-sparing aortic root replacement in 4 patients. Nineteen (76%) balloon-expandable valves, 5 (20%) self-expanding valves, and one mechanically-expandable (4%) valve were implanted with 100% procedural success, with no instances of significant paravalvular leak, coronary occlusion, or device embolization. There was one (4%) in-hospitality mortality after an emergency procedure; one (4%) patient experienced a transient ischemic attack; and two (8%) patients required permanent pacemaker implantation. The median length of hospital stay was 2 days. After a median follow-up time of 16.5 months, valve function was acceptable in all patients with available data. VIV-TAVI within stentless valves can be safely performed with methodical procedural technique and can provide clinical benefit in patients at high reoperation risk.

Aortic allografts for surgical treatment of prosthetic valve endocarditis

Background: Prosthetic valve endocarditis, the most severe form of infective endocarditis, occurs in 1-6% of patients with valve prostheses and is still associated with poor prognosis and high in-hospital mortality.Objective: To assess outcomes of allograft aortic root replacement in patients with prosthetic valve endocarditis.Methods: The retrospective analysis included adult patients with prosthetic valve endocarditis, who underwent allograft aortic root replacement between 2011 and 2022.Results: Of 15 study patients, early infective endocarditis was found in 60.0% of the cases. The most common cause was Staphylococcus aureus (26.7%). Early mortality was 13.3%. Thromboembolic events occurred in 2 patients (13.3%). The median follow-up period was 48.5 (6-140) months. Late death was reported in 1 patient. The 5-year survival rate was 79.0%. One patient had recurrent infective endocarditis. Two patients underwent reintervention: one for a proximal anastomotic pseudoaneurysm and another one for structural degeneration of the allograft. Five-year freedom from reintervention was 91.7%.Conclusion: Due to the high rate of the freedom from recurrent infective endocarditis, allograft aortic root replacement is an effective treatment for patients with prosthetic valve endocarditis. Received 7 November 2022. Revised 9 December 2022. Accepted 20 December 2022. Funding: The study was supported by the grant of the president of the Russian Federation (No. 075-15-2022-823). Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: A.V. Bogachev-ProkophievData collection and analysis: A.V. Karadzha, A.N. Pivkin, A.S. ZalesovStatistical analysis: R.M. Sharifulin, A.V. AfanasyevDrafting the article: R.M. Sharifulin, A.V. AfanasyevCritical revision of the article: A.V. Bogachev-Prokophiev, S.I. ZheleznevFinal approval of the version to be published: A.V. Bogachev-Prokophiev, R.M. Sharifulin, S.I. Zheleznev, A.V. Karadzha, A.V. Afanasyev, A.N. Pivkin, A.S. Zalesov

Primary Aortic Root Replacement Outcomes and Risk Factors in Pediatric Patients

The study sought to identify the optimal aortic root replacement (ARR) strategy for pediatric patients, and a single-center experience was analyzed. Retrospective review of patients undergoing ARR from 1995 to 2018 was performed. Patients were stratified by surgical strategy (pulmonary autograft [Ross procedure], aortic homograft, mechanical valve conduit [Bentall procedure], or porcine xenograft [Freestyle bioprosthesis]) and aortic annulus size. ARR was performed in 206 patients with a median follow-up of 5.0 (interquartile range, 1.4-11.4) years. Root replacements included Ross procedure (n= 98), homograft (n= 83), Bentall procedure (n= 18), and Freestyle bioprosthesis (n= 7). Overall survival was 92%, and freedom from reoperation or death was 81%. Reoperation-free survival was superior in the Ross group when compared with other groups. Because surgical options differ based on the size of the aortic annulus, the analysis was arbitrarily stratified. When the aortic annulus diameter was greater than 19 mm (n= 74), procedures included Ross procedure (n= 23), homograft (n= 29), Bentall procedure (n= 17), and Freestyle bioprosthesis (n= 5). Reoperation-free survival at median follow-up (5 years) was 86%, 58%, 100%, and 100%, respectively. The Bentall procedure offered the longest freedom from reoperation. In the subset with aortic annulus diameter less than 19 mm and a pulmonary valve suitable for a Ross procedure, patients underwent the Ross procedure (n= 75) or homograft ARR (n= 36). At median follow-up (3.8 years), reoperation-free survival was longer after the Ross procedure than after homograft ARR (88% vs 46%; P < .001). In patients with a large aortic annulus, a Bentall ARR offers the longest reoperation-free survival. For patients with small aortic roots, a Ross procedure provides better a reoperation-free survival than does homograft ARR.

Long-term survival after xenograft versus homograft aortic root replacement: Results from a prospective randomized trial

ObjectiveThe study objective was to investigate the long-term survival of patients undergoing xenograft versus homograft full root aortic valve replacement. MethodsA total of 166 patients requiring aortic valve surgery were randomized to undergo the Freestyle (Medtronic Inc, Minneapolis, Minn) bioprosthesis (N = 90) or a homograft (N = 76) full root aortic valve replacement between 1997 and 2005 in a single institution. Six patients randomly assigned to the homograft crossed over to the Freestyle bioprosthesis because of the unavailability of suitably sized homografts. All surgeons were required to adhere to the standard surgical technique for homograft root implantation previously described. Follow-up was 98.5% complete. ResultsThe mean age of the study population was 65 ± 8 years. Coronary artery bypass grafting was associated with root aortic valve replacement in 76 of 166 patients (46%, P = not significant between groups), and overall hospital mortality was 4.8% (8/166, P = not significant between groups). Median follow-up was 13.8 years (range, 0-21.8 years; 2033 patient-years). The Kaplan–Meier survival analysis showed that there was no significant difference in overall survival between the 2 arms at 5, 10, and 15 years. Twenty-year survival was 28.3% ± 5% for the Freestyle group versus 25.1% ± 5.7% for the homograft group (P = .90), which was comparable to the age- and sex-matched UK general population. The freedom from aortic valve reoperation at 20 years was comparable for the Freestyle group versus the homograft group (67.9% ± 8.8% vs 67.2% ± 10.3%, respectively; P = .74). ConclusionsThis is the first study to investigate the long-term survival of xenograft versus homograft full root aortic valve replacement from a prospective randomized trial. The observed 20-year overall survival and freedom from aortic valve reoperation serve as a benchmark for future studies on interventions for aortic valve disease in the elderly.

A RARE CAUSE OF INFECTIVE ENDOCARDITIS IN A LUNG TRANSPLANT PATIENT

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Infective endocarditis (IE) is characterized by high morbidity and mortality. Despite advances in medical and surgical therapy, mortality rates remain high. We describe a unique cause of IE in a transplant patient. CASE PRESENTATION: A 56 year-old female with a history of rheumatoid arthritis associated interstitial lung disease underwent bilateral lung transplant. Three months post operatively, she was diagnosed with culture negative endocarditis and had a bioprosthetic aortic valve (AV) replacement. A year later, she presented to the hospital with fatigue. Physical exam revealed a loud systolic murmur. Transthoracic echo demonstrated severe perivalvular aortic regurgitation around the bioprosthetic AV which was concerning for dehiscence. Transesophageal echo revealed a perivalvular abscess. She underwent a re-do sternotomy which revealed a dehisced bioprosthesis with multiple aortic root cavities and contained rupture. She had a homograft aortic root replacement and three vessel coronary artery bypass grafting due to poor integrity of the vessel orifices from the abscess. She was put on venous-arterial extracorporeal membrane oxygenation and had an intraortic balloon pump placed for myocardial stunning. During this time, she was treated with broad antimicrobials and antifungals. Operative cultures were negative as was extensive infectious evaluation including legionella urine antigen (Ag), histoplasma urine Ag and testing for other rarer infections. Operative tissue was sent for a universal PCR which resulted in Legionella feeleii 5 days later, and her antibiotics were changed to ciprofloxacin and doxycycline. Unfortunately, she progressed to multiorgan failure despite mechanical circulatory support, and the decision was made to transition to comfort care. DISCUSSION: L. feeleii was first described in 1984 as a causative agent of the Pontiac fever outbreak. L. feeleii has been responsible for 10 reported cases of infections, all of which were pneumonia, with one case complicated by pericarditis. This organism has a predilection for immunocompromised patients. Legionella urinary antigen testing does not reliably detect L. feeleii. PCR testing is sensitive and specific and provides the benefit of species identification but is not readily available in most clinical laboratories. CONCLUSIONS: L. feeleii is an extremely rare cause of infection in immunocompromised hosts. Its relatively high mortality rate warrants prompt diagnosis and appropriate management, but accurate diagnosis may be challenging because PCR testing is not routinely available. Reference #1: Loridant S, Lagier J-C, La Scola B. Identification of Legionella feeleii cellulitis. Emerg Infect Dis. 2011 Jan; 17(1): 145–146. Reference #2: Murdoch D, Corey R, Hoen B, et al. Clinical Presentation, Etiology, and Outcome of Infective Endocarditis in the 21st Century The International Collaboration on Endocarditis–Prospective Cohort Study. Arch Intern Med. 2009;169(5):463-473. DISCLOSURES: No relevant relationships by Laura Frye, source=Web Response No relevant relationships by Julie Lin, source=Web Response

Off-Label Sutureless Aortic Valve in the Failing Homograft

Homografts have been used in the aortic position as an alternative to xenograft or mechanical prostheses. With time, the leaflets and walls of the graft develop heavy calcification, making redo surgery hazardous. This study presented two patients who had successful sutureless bioprosthetic valve implantation into failing homografts, avoiding redo Bentall's procedure. It is believed that there has been one other report on the use of a sutureless aortic valve in this setting. The first patient is a 67-year-old male who underwent redo sternotomy, bioprosthetic aortic and mitral valve replacements and tricuspid annuloplasty. He initially underwent homograft aortic root, ascending aortic and hemiarch replacement in 1999 for a stenosed bicuspid aortic valve and aneurysmal aorta. He presented heart failure with pulmonary oedema. Transthoracic echocardiogram demonstrated a ruptured left coronary cusp, severe aortic, mitral, and tricuspid regurgitation, and pulmonary hypertension. Due to urgency and the extensive risk of a redo Bentall's procedure, he underwent a sutureless aortic valve implantation into the homograft. The patient was discharged home on postoperative day 10, after resolved delirium. Another 43-year-old male underwent homograft aortic root replacement in 1995 for bicuspid aortic valve and aortopathy. In 2018, he was diagnosed with severe aortic regurgitation secondary to perforated leaflets and redo surgery was planned with increased risk due to extensive calcification (“porcelain aorta”). After excision of the homograft leaflets, a large sutureless valve was inserted. The patient had an uncomplicated postoperative course. These two patients demonstrated that off-label use of the sutureless aortic valve in the failing homograft can be safely performed and offers an alternative strategy in management of these challenging patients.

Dacron Skirt Reconstruction of the Left Ventricular Outflow Tract: Extending the Capabilities of a Valved Conduit

Aortic root reconstruction in the setting of redo aortic valve procedures or infective endocarditis may be technically challenging, particularly because of variable destruction or distortion of the left ventricular outflow tract. Homograft aortic root replacement is an excellent option for aortic root abscesses but is limited by homograft availability. We describe a simple technique of a bioprosthetic valved conduit constructed on the table using a Dacron (DuPont, Wilmington, DE) skirt below the valve. The use of the Dacron skirt facilitates easy reconstruction of the left ventricular outflow tract.

Computed Tomography in Prosthetic Aortic Graft Infections

Prosthetic aortic grafts infection is associated with consider-able morbidity and mortality. Staphylococcus species are themost commonly implicated causative organisms. Computedtomography (CT) is the imaging modality of choice in theinvestigation of patients with suspected prosthetic aorticgraft infection, particularly in the assessment of abscessand pseudo-aneurysms associated with aortic graft infec-tions.WedescribetwocasesinwhichCTprovidesincremen-tal information about the complications associated withprosthetic aortic graft infection which is essential in guidingtreatment and management.Case 1: 45 year-old man with previous Bentall’s graft with25 mm St Jude valve conduit for bicuspid aortic valve anddilated aortic root presented with night sweats, weight loss,and rash. Transthoracic echocardiogram (Fig. 1A, video I)demonstrated a large pseudo-aneurysm anterior to the Ben-tall’s with free moving echogenic mass within likely consis-tent with vegetations. CT thoracic aorta (Fig. 1B-1D) showeda large complex pseudo-aneurysm anterior to the aortic rootand the main pulmonary artery with fistula origin at theright coronary artery anastomosis. He subsequently under-went redo Bentall’s procedure with 23 mm ATS bileafletmechanical valve and 30 mm Gelweave valsalva graft. Sur-gery confirmed a large pseudo-aneurysm arising from theaortic root with vegetations in the cavity. Propionibacteriumacnes was isolated and he was treated with six weeks ofintravenous benzyl penicillin followed by oral penicillinfor three months.Case 2: 19 year-old man with end-stage renal failure pre-sented with an aortic root abscess (Fig. 2A) secondary toMethicillin-resistant Staphylococcus aureus bacteraemia withthe presumed infection likely arising from right internaljugular tunnelled line for haemodialysis. He underwent anurgent homograft aortic root replacement in view of severeaorticincompetence(Fig.2B)and completeheartblock.Post-operative echocardiogram (Fig. 2C & 2D, videos II & III)showedalargeparavalvularechofreespaceposteromediallyand another anterolaterally consistent with pseudo-aneurysm. CT thoracic aorta (2E & 2F) demonstrated twopseudo-aneurysms arising from the left ventricular outflowtract. Redo aortic root replacement was performed but com-plicated by significant bleeding from the root despite multi-ple suturing, topical measures and packing, and eventuallyhe died.Keywords Computer tomography Echocardiogram Prosthetic aortic graft infections

024 Cryopreservation management and its impact on graft function with heart valve allograft

Cryopreserved aortic valve allograft (homograft) is a graft of choice in managing aortic root replacement (ARR) surgery for critical infective endocarditis (IE). Homografts provide favorable clinical outcome in terms of regulating infection in preoperative period and providing superior hemodynamic performance because of their natural structure, however, long-term graft durability is still a matter of discussion, and reoperation is considered very challenging in those cases. Among the possible factors that may influence long-term graft durability and function, we reviewed homograft-oriented factors including their storage period along with the long-term clinical outcome of the patients receiving homograft ARR for IE cases. Patients undergoing homograft ARR for critical IE were reviewed for recipients’ preoperative profile and postoperative short and long term results including redo aortic valve replacement (AVR). The information of implanted homograft tissue including donor age, gender, blood type, warm ischemic time (WIT), and duration of storage at tissue bank (−180 °C) until use. Long-term results were evaluated among the patients who were able to be discharged home after the surgery. Cryopreserved homografts were prepared using programmable freezer with freezing rate of −1 °C/min until −80 °C, and stored at vapor phase of liquid nitrogen under temperature control between −170 and −180 °C. Before 2006, liquid nitrogen was supplied manually, and it was supplied automatically after 2006. Student t -test was performed to compare 2 groups (DR and HI), and long-term results were evaluated by Kaplan Meier curve, with p < 0.05 being statistical significance. From December 1998 through April 2013, there were 37 consecutive patients including 34 prosthetic valve endocarditis cases (92%). Thirty patients were male (81%), and average age was 55 ± 13 years. Twenty-eight cases (75%) presented annular destruction with abscess formation. In-hospital mortality was 16.2% (6/37) including 3 cases lost within 30 days after surgery (30-day mortality 8.1%). Seven cases underwent redo aortic valve replacement in the late period for degenerative change of the valve leaflets and IE of the homografts. Gender and blood type mismatch were seen in 18 (49%) and 8 cases (22%) respectively, and these factors did not have any impact on valvular impairment requiring redo AVR, and so was WIT. Average storage period of the grafts was 708 days, and there was a significant difference between those who required redo AVR and those who did not (242 days vs. 840 days, p < 0.0001). Six tissues which required redo AVR was stored in the tank with periodical manual supply of liquid nitrogen, and 1 tissue was in the tank with automatic supply. Long-term overall cumulative survival at 1/5/10/14 year were 92.7/74.5/61.2/61.2% respectively. Freedom from redo AVR at1/5/10/14 year were 92.6/79.5/79.5/39.7%. Long-term durability of the homografts was satisfactory, which is almost reaching to the value of bioprosthetic valves. Automatic liquid nitrogen supplying system may be beneficial in quality control of the heart valve tissues. Source of funding: None declared. Conflict of interest: None declared. ayasaitou-ths@umin.ac.jp

Sutureless Perceval Aortic Valve Replacement in Aortic Homograft

We report a case of aortic valve replacement with a sutureless valve in a degenerated aortic homograft. This technique allows rapid aortic valve replacement in a heavily calcified aortic root. It avoids the problems of postoperative prosthetic disinsertion frequently encountered after aortic valve replacement in a calcified annulus. It is particularly suitable in redo procedures for homograft degeneration. It avoids performing a redo Bentall operation with its known morbidity.

Near-Complete Obstruction of an Aortic Homograft

Aortic valve replacement in the setting of aortic valve endocarditis frequently is managed with an aortic homograft. However, late operation is not uncommon and may be very difficult because of calcification of the wall of the aortic homograft and the valve leaflets.1–3 We report a patient with a heretofore unreported complication with near-complete obstruction of his aortic homograft. A 38-year-old man was referred to the Bluhm Cardiovascular Institute at Northwestern University for surgical management of suspected aortic prosthesis dysfunction. He had undergone aortic valve replacements at 16 and 24 years of age, and at 25 years of age, he developed prosthetic valve endocarditis, which was treated with cryopreserved homograft aortic valve and root replacement. He required partial sternectomy for sternal osteomyelitis weeks later and an implantable cardioverter-defibrillator for perioperative ventricular arrhythmias. He recovered fully. In 2009, the patient developed weekly episodes of numbness, paresthesia, and weakness lasting from 15 minutes to several hours. In the fall of 2010, progressive fatigue and dyspnea on exertion progressed to near syncope. Echocardiographic (Figure 1) and computed tomography (Figure 2) scans suggested obstruction of the aortic homograft. At Northwestern, echocardiographic imaging from the apical transducer position demonstrated no aortic stenosis or regurgitation with a mean gradient of 6 mm Hg across the valve (Figure 1A). …

Mid- to long-term outcomes of cardiovascular tissue replacements utilizing homografts harvested and stored at Japanese institutional tissue banks

We reviewed our clinical experiences with cardiovascular homografts harvested and preserved at our institutional tissue banks. Since our bank was first established in Japan in 1990, 74 patients have undergone various surgical procedures using homografts. We classified them into five groups according to the procedure: Group I, subcoronary implantation of a homograft aortic valve; Group II, homograft aortic root replacement for active native or prosthetic endocarditis; Group III, homograft aortic replacement for mycotic aortic aneurysms or infected grafts; Group IV, pulmonary homografts in the Ross operation; and Group V, pulmonary homograft conduits for complex congenital heart diseases. The 9- to 10-year survival rates were good and acceptable, respectively, for the patients in all five groups. The infection recurrence rate was low (8%). Cardiac event-free rates, including deaths, were 0.57 in Group I, 0.58 Group in II, 0.75 in Group III, 0.81 in Group IV, and 0.69 in Group V operations. The rates of structural homograft deterioration suggest that homografts deteriorate more rapidly after subcoronary implantation than aortic root replacements (P = 0.058). Subcoronary implantation should probably be abandoned for routine aortic valve replacement, but the continued use of homografts will provide valuable alternatives for patients with active infectious cardiovascular diseases. For the Ross operation, pulmonary valve homografts showed good durability.

Recurrent Pseudomonas aortic root abscess complicating mitral valve endocarditis

We report on a man with Pseudomonas aeruginosa endocarditis causing an aortic root abscess. He underwent surgery with a homograft aortic root replacement and insertion of a tissue aortic valve. The patient then manifested recurrent aortic root infection and respiratory arrest, and eventually succumbed to sepsis. This case highlights the aggressive nature of an uncommon pathogen causing an atypical but lethal form of endocarditis, despite modern medical and surgical treatment.

Late Outcomes Following Freestyle Versus Homograft Aortic Root Replacement: Results From a Prospective Randomized Trial

Late Outcomes Following Freestyle Versus Homograft Aortic Root Replacement: Results From a Prospective Randomized Trial

Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial

The ideal substitute for aortic valve replacement in patients with aortic valve disease is not known. Our hypothesis was that the regulatory and adaptive properties of a living valve substitute could improve the long-term outcomes in patients. We therefore compared these outcomes after autograft aortic root replacement (Ross procedure) versus homograft aortic root replacement in adults. Male and female patients (<69 years) requiring aortic valve surgery were randomly assigned in a one-to-one ratio to receive an autograft or a homograft aortic root replacement in one centre in the UK. The random allocation sequence was computer generated. Treatment was not masked. The primary endpoint was survival of patients at 10 years after surgery. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN03530985. 228 patients were randomly assigned to receive an autograft or a homograft aortic root replacement. 12 patients were excluded because they were younger than 18 years; 108 in each group received the surgery they were assigned to and were analysed. There was one (<1%) perioperative death in the autograft group versus three (3%) in the homograft group (p=0.621). At 10 years, four patients died in the autograft group versus 15 in the homograft group. Actuarial survival at 10 years was 97% (SD 2) in the autograft group versus 83% (4) in the homograft group. Hazard ratio for death in the homograft group was 4.61 (95% CI 1.71-16.03; p=0.0060). Survival of patients in the autograft group was similar to that in an age-matched and sex-matched British population (96%). Our findings support the hypothesis that a living valve implanted in the aortic position can significantly improve the long-term outcomes in patients. Funding Magdi Yacoub Institute.

Late Outcomes Following Freestyle Versus Homograft Aortic Root Replacement: Results From a Prospective Randomized Trial

The aims of this study were to compare long-term results after homograft versus Freestyle (Medtronic Inc., Minneapolis, Minnesota) aortic root replacement. The ideal substitute for aortic root replacement remains undetermined. Between 1997 and 2005, 166 patients (age 65 +/- 8 years) undergoing total aortic root replacement were randomized to receive a homograft (n = 76) or a Freestyle bioprosthesis (n = 90). Six patients randomly assigned to homograft crossed over to Freestyle because of unavailability of suitably sized homografts. Median follow-up was 7.6 years (maximum 11 years; 1,035 patient-years). "Evolving" aortic valve dysfunction was defined as aortic regurgitation >/=2/4 and/or peak gradient >20 mm Hg. Patient characteristics were comparable between groups. Concomitant procedures were performed in 44% and 47% of Freestyle and homograft patients, respectively (p = 0.5). Overall hospital mortality was 4.8% (1% for isolated root replacement). Eight-year survival was 80 +/- 5% in the Freestyle group versus 77 +/- 6% in the homograft group (p = 0.9). Freedom from need for reoperation at 8 years was significantly higher after Freestyle root replacement (100 +/- 0% vs. 90 +/- 5% after homograft replacement; p = 0.02). All reoperations were secondary to structural valve deterioration (n = 6). At last echocardiographic follow-up, actuarial freedom from evolving aortic valve dysfunction was 86 +/- 5% for Freestyle bioprostheses versus 37 +/- 7% for homografts (p < 0.001). Clinically, freedom from New York Heart Association functional class III to IV and freedom from valve-related complications were similar between groups (p = 0.7 and p = 0.9, respectively). In this patient group, late survival is similar after homograft versus Freestyle root replacement. However, Freestyle aortic root replacement is associated with significantly less progressive aortic valve dysfunction and a lower need for reoperations.

Homograft aortic root replacement in native or prosthetic active infective endocarditis: Twenty-year single-center experience

We compared early and long-term results of cryopreserved homograft aortic root replacement in native valve endocarditis or prosthetic valve endocarditis associated with periannular abscess. Between May 1986 and December 2007, 1163 patients with endocarditis were operated upon. Of these, 221 patients (n = 185 men, median age 55 years) had homograft aortic root replacement due to 99 cases of native valve endocarditis (45%) and 122 of prosthetic valve endocarditis (55%). Perinannular abscess developed in 189 patients (86%), and aortoventricular dehiscence in 120 (63.5%) of them. Perioperative characteristics, probability of survival, freedom from recurrence, and reoperation were analyzed. Follow-up (mean 5.2 +/- 0.4 years, maximum 18.4 years) was completed in 96.8% with a total of 1127 patient-years. Overall native valve endocarditis survival at 30 days and 1, 5, and 10 years was 83.8% +/- 3.7%, 76.6% +/- 4.3%, 66.5% +/- 4.9%, and 47.3% +/- 5.6%, respectively, significantly better than for patients with prosthetic valve endocarditis, who had a greater tendency toward abscess formation (P = .029). Thirty-one patients (14.0%) required reoperation either for structural valve deterioration (n = 19, 8.6%), with a greater tendency in patients aged <40 years, or for recurrent endocarditis of the homograft (n = 12, 5.4%). One-year reoperation mortality rate was 16.1% (n = 5). Homograft aortic root replacement in active infective endocarditis with periannular abscess formation shows satisfactory early and long-term results with significantly better survival in native valve endocarditis than prosthetic valve endocarditis. It is associated with a low recurrence rate, although the risk of structural valve deterioration increases over time, especially in young patients, and reoperation remains a challenge. In our institution, the homograft remains the preferred valve substitute in active infective endocarditis with periannular abscess formation.

Rate of Progression and Functional Significance of Aortic Root Calcification After Homograft Versus Freestyle Aortic Root Replacement

Calcification is an important limitation after aortic root replacement. The aims were to compare the long-term degree and rate of calcification of homografts versus Medtronic freestyle aortic roots to determine the functional consequences and predictive factors. One hundred sixty-six patients were prospectively randomized to undergo homograft versus freestyle total aortic root replacement. Of those, 98 patients underwent a total of 248 electron beam computed tomography studies at 0.5, 1, 1.5, 2, 3, and 8 years. All patients underwent yearly clinical and echocardiographic follow-up. Calcium scores were measured using Agatston scoring. Mixed effects models demonstrate significantly higher calcium scores in homograft roots than freestyle at 1.5 years (P=0.02), 2 years (P=0.02), and 3 years (P=0.01), with a trend at 1 year (P=0.06) and 8 years (P=0.1). Homograft calcification occurs significantly faster than in freestyle prostheses between 6 months and 3 years after surgery (P=0.02). Calcification occurs at a similar rate thereafter up to 8 years (P=0.3). At 8 years, freedom from aortic valve dysfunction was lower in homografts than freestyle roots (P=0.06). Freedom from reoperation was 93+/-4% in the homograft group versus 100+/-0% in the freestyle group at 8 years (P=0.01). On multivariate analysis, redo surgery (P<0.001), smoking (P<0.01), atrial fibrillation (P=0.001), family history of coronary artery disease (P<0.01), and a degenerative etiology (P=0.02) were predictive of higher calcium scores. Homograft roots exhibit significantly higher calcium scores than freestyle roots because of faster early calcification.

Predictors of early mortality in patients with active infective native or prosthetic aortic root endocarditis undergoing homograft aortic root replacement

We compared early results of homograft aortic root replacement (ARR) in native (NVE) and prosthetic (PVE) aortic valve endocarditis in order to identify predictors for early mortality (<30 days). Between 05/1986 and 12/2007, 1,163 endocarditis patients were operated upon. Of these, 221 patients (n = 185 men, median age 55 years) underwent homograft ARR due to 99 cases of NVE (45%) and 122 of PVE (55%) aortic root endocarditis. Demographics, clinical differences, survival rates and predictors of early mortality were analyzed. Follow-up (mean 5.2 +/- 0.4 years, maximum 18.4 years) was completed in 96.8% with a total of 1,127 patient years. Main causes of the 47 (21.2%) early deaths were septic multiorgan failure in 23 (48.9%) and myocardial failure in 10 (21.3%) patients with a significantly better survival for NVE than for PVE patients (patients = 0.029). The highest ORs were found in the univariate analysis for preoperative development of septic shock (OR 14.28), preoperative necessity of ventilation (OR 7.08), high doses of catecholamines (OR 5.60), severe aortic root destruction (OR 5.12), emergency operation (OR 4.25) and persistent fever despite antibiotic treatment (OR 4.11). Multivariate analysis showed that preoperative ventilation (OR 5.43), persistent fever under antibiotic treatment (OR 2.84) and prosthetic endocarditis (OR 2.32) were independent risk factors for early mortality. Our results suggest that early outcome could be improved if patients were referred earlier for surgery. A multidisciplinary approach is necessary, involving at least specialists in intensive care medicine, cardiology, infectious disease and cardiac surgery in order to identify the optimal time for surgery and decrease early mortality.