Homograft Aortic Valve Replacement Research Articles

The Ross procedure is the optimal solution for young adults with unrepairable aortic valve disease.

While aortic valve repair remains the ideal intervention to restore normal valvular function, the optimal aortic valve substitute for patients with a non-repairable aortic valve remains an ongoing subject for debate. In particular, younger patients with a non-repairable valve represent a unique challenge because of their active lifestyle and long life expectancy, which carries a higher cumulative risk of prosthesis-related complications. The Ross procedure, unlike prosthetic or homograft aortic valve replacement (AVR), provides an expected survival equivalent to that of the age and gender-matched general population. Contemporary data has shown that the Ross procedure can be performed safely in centers with expertise, and is associated with improved valvular durability, hemodynamics and quality of life.

Long-term outcomes of valve-in-valve transcatheter aortic valve implantation for degenerate homograft aortic valve replacement.

Long-term outcomes of valve-in-valve transcatheter aortic valve implantation for degenerate homograft aortic valve replacement.

The Ross procedure versus prosthetic and homograft aortic valve replacement: a systematic review and meta-analysis.

Young adults undergoing aortic valve replacement (AVR) have decreased life expectancy compared to matched controls. The Ross procedure aims to improve valve lifespan while avoiding anticoagulation. We prepared a systematic review and meta-analysis to assess the Ross procedure compared to conventional AVR. We searched MEDLINE, EMBASE and Cochrane CENTRAL for studies evaluating the Ross procedure versus any conventional AVR in adult patients. We performed screening, full-text assessment, risk of bias evaluation and data collection independently and in duplicate. We evaluated the risk of bias with the ROBINS-I and Cochrane tools and quality of evidence with the GRADE framework. We pooled data using the random- and fixed-effects models. Thirteen observational studies and 2 randomized controlled trials (RCTs) were identified (n = 5346). No observational study was rated as having low risk of bias. The Ross procedure was associated with decreased late mortality in observational and RCT data [mean length of follow-up 2.6 years, relative risk (RR) 0.56, 95% confidence interval (CI) 0.38-0.84, I2 = 58%, very low quality]. The RCT estimate of effect was similar (mean length of follow-up 8.8 years, RR 0.33, 95% CI 0.11-0.96, I2 = 66%, very low quality). No difference was observed in mortality <30 days after surgery. All-site reintervention was similar between groups in cohorts and significantly reduced by the Ross procedure in RCTs (RR 1.41, 95% CI 0.89-2.24, I2 = 55%, very low quality and RR 0.41, 95% CI 0.22-0.78, I2 = 68%, high quality, respectively). Observational data, with residual confounding, and RCT data suggest a late survival benefit with the Ross procedure with no increased risk of reintervention when compared to conventional AVR. Considering the quality of available evidence and limited follow-up, additional high-quality randomized studies are required to strengthen these findings. CRD42016052512.

Aortic Valve Replacement and the Ross Operation in Children and Young Adults

BackgroundThere are several options available for aortic valve replacement (AVR), with few comparative reports in the literature. The optimal choice for AVR in each age group is not clear. ObjectivesThe study sought to report and compare outcomes after AVR in the young using data from a national database. MethodsAVR procedures were compared after advanced matching, both in pairs and in a 3-way manner, using a Bayesian dynamic survival model. ResultsA total of 1,501 patients who underwent AVR in the United Kingdom between 2000 and 2012 were included. Of these, 47.8% had a Ross procedure, 37.8% a mechanical AVR, 10.9% a bioprosthesis AVR, and 3.5% a homograft AVR, with Ross patients being significantly younger when compared to the other groups. Overall survival at 12 years was 94.6%. In children, the Ross procedure had a 12.7% higher event-free probability (death or any reintervention) at 10 years when compared to mechanical AVR (p = 0.05). We also compared all procedures except the homograft in a matched population of young adults, where the bioprosthesis had the lowest event-free probability of 78.8%, followed by comparable results in mechanical AVR and Ross, with 86.3% and 89.6%, respectively. Younger age was associated with mortality and pulmonary reintervention in the Ross group and with aortic reintervention in the mechanical AVR. Of all 3 options, only the patients undergoing the Ross procedure approached the survival of the general population. ConclusionsAVR in the young achieves good results, with the Ross being overall better suited for this age group, especially in children. Although freedom from aortic valve reintervention is superior after the Ross procedure, the need for homograft reinterventions is an issue to take into account. All methods have advantages and limitations, with reinterventions being an issue in the long term for all, more crucially in smaller children.

Invited Commentary

Invited Commentary

Outcome after aortic valve replacement in children: A systematic review and meta-analysis

ObjectiveDespite an increasing interest in pediatric aortic valve repair, aortic valve replacement in children may be unavoidable. The evidence on outcome after pediatric aortic valve replacement is limited and usually reported in small case series. This systematic review and meta-analysis aims to provide an overview of reported outcome of pediatric patients after aortic valve replacement. MethodsA systematic literature search for publications reporting outcome after pediatric aortic valve replacement published between January 1990 and May 2015 was conducted. Studies written in English with a study size of more than 30 patients were included. ResultsThirty-four publications reporting on 42 cohorts were included in this review: 26 concerning the Ross procedure (n = 2409), 13 concerning mechanical prosthesis aortic valve replacement (n = 696), and 3 concerning homograft aortic valve replacement (n = 224). There were no studies on bioprostheses that met our inclusion criteria. The pooled mean patient age was 9.4 years, 12.8 years, and 8.9 years for Ross, mechanical prosthesis, and homograft recipients, respectively. Pooled mean follow-up was 6.6 years. The Ross procedure was associated with lower early (4.20%; 95% confidence interval [CI], 3.37-5.22 vs 7.34%; 95% CI, 5.21-10.34 vs 12.82%; 95% CI, 8.91-18.46) and late mortality (0.64%/y; 95% CI, 0.49-0.84 vs 1.23%/y; 95% CI, 0.85-1.79 vs 1.59%/y; 95% CI, 1.03-2.46) compared with mechanical prosthesis aortic valve replacement and homograft aortic valve replacement, respectively. No significantly different aortic valve reoperation rates were observed between the Ross procedure and mechanical prosthesis aortic valve replacement (1.60%/y; 95% CI, 1.27-2.02 vs 1.07%/y; 95% CI, 0.68-1.68, respectively), whereas homograft aortic valve replacement was associated with significantly higher aortic valve reoperation rates (5.44%/y; 95% CI, 4.24-6.98). The Ross procedure–associated right ventricular outflow tract reoperation rate was 1.91% per year (95% CI, 1.50-2.44). ConclusionsThis systematic review illustrates that all currently available aortic valve substitutes are associated with suboptimal results in children, reflecting the urgent need for reliable and durable repair techniques and innovative replacement solutions for this challenging group of patients.

Capturing echocardiographic allograft valve function over time after allograft aortic valve or root replacement

This study describes echocardiographic allograft valve function over time in a cohort of patients who were prospectively followed after allograft aortic valve or root replacement, illustrating the use of longitudinal data analysis for assessing valve function over time. Serial, standardized echocardiographic measurements of aortic regurgitation, aortic gradient, annulus diameter, left ventricular outflow tract diameter, and aortic diameter in 301 hospital survivors (mean age, 46 years; range, 16-83 years) after allograft aortic valve (N=77) or root (N=224) replacement were analyzed using nonlinear longitudinal models. Aortic regurgitation increased over time. At 15 years, 41% of patients had at least moderate aortic regurgitation. Younger patient age and subcoronary implantation technique were associated with increased aortic regurgitation. Aortic gradient increased over time (from 9.4 mm Hg at 6 months to 21.3 mm Hg at 15 years); both initial and increase in aortic gradient were greater in younger patients and after subcoronary implantation technique. Annulus diameter slightly increased (from 21.9 mm at 6 months to 22.4 mm at 15 years), whereas aortic diameter slightly decreased over time (from 34.3 mm at 6 months to 32.7 mm at 15 years). Left ventricular outflow tract diameter remained constant at 22 mm. Younger patients in the subcoronary implantation group had a larger annulus diameter. Both aortic regurgitation and stenosis increase over time after allograft aortic valve or root replacement. Younger patient age and use of the subcoronary implantation technique are associated with increased regurgitation and stenosis. The use of nonlinear longitudinal models allows for an insightful analysis of allograft valve function over time.

Transcatheter aortic valve implantation (TAVI) in a patient with severe aortic insufficiency of aortic valve homograft

We present the case of a 64-year-old female who was admitted to our centre with severe aortic insufficiency and advanced heart failure symptoms (NYHA class III–IV). Her medical history included: surgical homograft aortic valve replacement due to severe aortic insufficiency 14 years ago, chronic atrial fibrillation, and hypothyroidism. The patient’s logistic EuroSCORE was 32%, EuroSCORE II 9.1%, and STS score 3.95%. Preprocedural transthoracic echocardiographic examination revealed akinesis of the basal and mid segments of interventricular septum, global hypokinesis of remaining segments with ejection fraction of 19%, enlargement of the left ventricle and atrium (diameter of 68 and 43 mm, respectively), regurgitant orifice area of 0.3 cm2, regurgitant volume of 58 mL, and regurgitant jet width to left ventricular outflow tract ratio of 66% (Fig. 1). An additional transoesophageal echocardiographic examination was performed for more precise measurement: this showed aortic annulus diameter of 24 mm. Angiography and computed tomography were also performed, showing no lesions in either the coronary or peripheral arteries. On the basis of the abovementioned clinical conditions, the Heart Team decided to refer the patient to transcatheter aortic valve implantation (TAVI) via femoral access. The procedure was performed under general anaesthesia with a temporary pacemaker placed through the jugular vein and vascular access obtained with 18 Fr sheath by puncture of the right femoral artery. Due to lack of calcifications, two pig-tail catheters were placed in order to mark the plane of the annulus (Fig. 2) and 29 mm Medtronic CoreValveTM bioprosthesis was implanted under rapid pacing. Despite these preventive measures, the final position of prosthesis was too low with moderate-to-severe aortic insufficiency (Fig. 3) that persisted even after postdilatation with a 28 mm balloon. Therefore, the decision to implant another 29 mm CoreValve 10 to 15 mm higher was made. Finally, in control imaging, only a mild paravalvular leak was present (Fig. 4), and on discharge the ejection fraction had improved to 43%. TAVI is an effective treatment option for severe aortic stenosis in inoperable and high-risk patients. However, failure (mostly insufficiency) of a previous homograft aortic valve poses a challenge for any interventional treatment. In selected patients, TAVI can be a feasible alternative for high risk re-operation. TAVI may also be considered in some cases of native aortic insufficiency where there is favourable anatomy.

Aortic valve replacement in neonates and infants: An analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database

We sought to describe early outcomes of aortic valve replacement in neonates and infants across a large multicenter cohort. Neonates and infants in the Society of Thoracic Surgeons Congenital Heart Surgery Database undergoing nontruncal aortic valve replacement with the Ross-Konno procedure, Ross procedure, or homograft replacement from 2000 to 2009 were included. Preoperative characteristics, operative data, and early outcomes are described. A total of 160 patients (43 neonates, 117 infants) from 47 centers were included. Society of Thoracic Surgeons-defined preoperative risk factors were present in 76 patients (48%) and were most prevalent in neonates (67%) and patients undergoing homograft aortic valve replacement (93%). Concomitant arch repair or mitral valve surgery was performed in 30 patients (19%) and 19 patients (12%), respectively. Postoperative mechanical circulatory support was used in 17 patients (11%). Overall in-hospital mortality was 18% and was highest for neonates (28%) and patients undergoing homograft aortic valve replacement (40%). Concomitant arch repair was associated with higher in-hospital mortality (33% vs 15%, P=.02), whereas concurrent mitral valve surgery was not (21% vs 18%, P=.73). Postoperative mechanical circulatory support was also associated with increased in-hospital mortality (65% vs 13%, P<.0001). Neonates and infants undergoing aortic valve replacement are a high-risk group, with hospital mortality comparable with some of the highest risk procedures in this age group. The requirement for arch repair or postoperative mechanical circulatory support was associated with an increased risk of death in this cohort.

Pseudoaneurysms of the Heart

Case 1 : An 85-year-old man with a history of ischemic cardiomyopathy and recent reoperation coronary bypass surgery was noted on a routine follow-up echocardiogram to have a 25×25-mm fluid-filled extracardiac mass adjacent to the basal inferolateral wall of the left ventricle (Figure 1). Cardiac computed tomography (CT) identified the structure to be a pseudoaneurysm of a saphenous vein graft to an obtuse marginal branch of the left circumflex coronary artery. How should this patient be managed? Figure 1. Saphenous vein graft (SVG) pseudoaneurysm in an 85-year-old man after recent reoperation coronary artery bypass surgery. The pseudoaneurysm was visible as a mass (arrow) in the left atrioventricular (AV) groove on the chest x-ray ( A ). Transthoracic echocardiography ( B ) demonstrated a vascular mass (arrow) adjacent to the basal lateral wall. Cardiac computed tomographic angiography ( C ) demonstrated the pseudoaneurysm (arrow) connecting to the SVG by a narrow neck with contrast enhancement (light gray) and some thrombus (dark gray). Four-chamber view ( D ) demonstrating the pseudoaneurysm (arrow) in the left AV groove; a magnified view ( D , inset) demonstrates the pseudoaneurysm connected to the SVG via a narrow neck (arrow) with active contrast extravasation (red outline) contained by thrombus (white outline). Invasive angiography showing contrast extravasation ( E ) into the pseudoaneurysm (arrow) and postintervention angiogram demonstrated successful occlusion of the pseudoaneurysm ( F ). LA indicates left atrium; LV, left ventricle. Case 2 : A 27-year old man with prior homograft aortic valve replacement developed recurrent endocarditis (Figure 2). Echocardiography noted a periaortic valvular fluid collection concerning for abscess or valvular dehiscence. However, Doppler signal to and from the fluid collection connecting to the left ventricular outflow tract also raised concern for pseudoaneurysm. Cardiac CT confirmed the structure to be a 37×32-mm pseudoaneurysm involving the left coronary cusp of a trileaflet homograft prosthetic aortic valve just below the takeoff of …

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). …

Transapical aortic valve implantation after previous homograft aortic valve replacement

Background: Morbidity and mortality of surgical aortic valve replacement (AVR) are increased in patients with previous heart surgery. Especially patients after homograft AVR carry an increased risk. Transapical aortic valve implantation (TAVI) may be an option to reduce mortality and morbidity in this special patient group.

Propensity analysis of survival after subcoronary or root replacement techniques for homograft aortic valve replacement

Homograft aortic valve replacement is associated with excellent clinical and hemodynamic outcomes. Valves are implanted predominantly by using 2 techniques: the freehand subcoronary technique or as an aortic root replacement. Our aim was to identify any difference in survival, durability, and clinical performance. Demographic, operative, and clinical data were obtained retrospectively through case-note review. All operations were performed by a single surgeon. Propensity score-adjusted analysis was used by developing a nonparsimonious logistic regression model for implantation with subcoronary versus root replacement. Actuarial survival and freedom from valve-related events were compared with Kaplan-Meier curves and multivariable proportional hazard Cox regression. Between January 1, 1991, and January 1, 2001, 215 patients underwent aortic valve replacement with a homograft. The subcoronary technique was used in 131 (61%) patients. Eighty-four (39%) patients underwent free-standing aortic root replacement. After propensity risk adjustment, the subcoronary implantation technique was associated with a decreased risk of 30-day death (adjusted odds ratio, 0.18; 95% confidence interval, 0.06-0.34; P = .03). Technique of insertion was not an independent predictor of overall mortality during follow-up after adjustment (propensity adjusted hazard ratio, 0.35; 95% confidence interval, 0.09-1.41; P = .18). There were no significant differences in 1- and 5-year actuarial survival, freedom from structural valve disease, endocarditis, or reoperation. Both the subcoronary and root replacement techniques for homograft aortic valve replacement are associated with excellent midterm survival and clinical performance. Root replacement was associated with an increased risk of perioperative death after adjustment for covariates by using propensity analysis.

Autograft or allograft aortic valve replacement in young adult patients with congenital aortic valve disease

Autograft or allograft aortic valve replacement in young adult patients with congenital aortic valve disease

Valve failure following homograft aortic valve replacement: does implantation technique have an effect?

Structural valve deterioration (SVD) limits the long-term durability of homograft aortic valve replacement (AVR). Valves are implanted predominantly using two techniques, the free-hand sub-coronary (SC) technique or aortic root replacement (RR). Our objective was to identify risk factors associated with the development of SVD or ascending aortic dilatation. In particular we strived to determine whether the mode of implantation had an independent effect. Demographic and pre-operative clinical data were obtained retrospectively through case-note review. All operations were performed by a single surgeon. Actuarial freedom from >or=2+ AR (aortic regurgitation), elevated trans-valvular gradient (TVG) (>or=25 mmHg) and ascending aortic dilatation (>or=4.0 cm) were assessed using Kaplan-Meier curves and multivariable Cox proportional hazards regression. A propensity analysis was carried out using a non-parsimonius logistic regression model for implantation with SC vs. RR. Between 1 January 1991 and 1 January 2001, 215 patients underwent AVR with a homograft. The SC technique was used in 131 (61%) patients and 84 (39%) patients underwent RR. Technique was not an independent predictor for >or=2+ AR (adjusted hazard ratio 1.9; 95% CI 0.56-6.16, P = 0.31), elevated TVG (adjusted hazard ratio; 0.99; 95% CI 0.15-6.71, P = 0.99) or ascending aortic dilatation (adjusted hazard ratio 2.01; 95% CI 0.50-8.25, P = 0.33). One and 5 year actuarial freedom from >or=2+ AR (log-rank - P = 0.09) and ascending aortic dilatation (log-rank - P = 0.88) were not significantly different between groups. The incidence of SVD and ascending aortic dilatation is not affected by the method of implantation of the aortic homograft. All homografts are prone to SVD which is responsible for a progressive increase in the prevalence of these changes over time.

Autograft or allograft aortic valve replacement in young adult patients with congenital aortic valve disease

We analysed the outcome of young adults with congenital aortic valve disease who underwent allograft or autograft aortic valve or root replacement in our institution and evaluated whether there is a preference for either valve substitute. Between 1987 and 2007, 169 consecutive patients with congenital aortic valve disease aged 16-55, participating in our ongoing prospective follow-up study, underwent 63 autograft and 106 allograft aortic valve replacements (AVRs). Mean age was 35 years (SD 10.8), 71% were males. Aetiology was 71% bicuspid valve, 14% other congenital, and 15% BV endocarditis. Twenty-two percent underwent previous cardiac surgery; 11% had an ascending aorta aneurysm. Two patients died in hospital. During follow-up six more patients died and 45 patients required valve-related re-operations. Thirteen-year survival was 97% for autograft and 93% for allograft recipients, 13 year freedom from valve-related re-operation was 63% for autograft and 69% for allograft patients. In patients with congenital aortic valve disease, autograft and allograft AVR show comparable satisfactory early and long-term results, with the increasing re-operation risk in the second decade after operation remaining a major concern.

Subcoronary Allograft Aortic Valve Replacement: Parametric Risk-Hazard Outcome Analysis to a Minimum of 20 Years

Differences in sterilization, preservation, and implantation have been implicated in aortic allograft longevity. We report follow-up to 30 years of patients from a single unit who underwent aortic valve replacement with aortic allografts sterilized in antibiotics and refrigerated at 4 degrees C. Two hundred consecutive patients underwent subcoronary allograft aortic valve replacement and have been followed up to a minimum of 20 and maximum of 30 years. Follow-up was 96% complete. Parametric hazard phase modeling was used to identify incremental predictors of time-related risk. Early mortality was 1.5%. Kaplan-Meier actuarial survival, including early death, was 81.2% +/- 2.8% (mean +/- standard error of the mean), 58.0% +/- 3.7%, and 52% +/- 5.1% at 10, 20, and 25 years, respectively. Freedom from reoperation for any reason was 86.4% +/- 2.6%, 39.6% +/- 5.2%, and 35.0% +/- 5.4% at 10, 20, and 25 years, respectively. Larger implanted valve, reexploration for bleeding, previous cardiac surgery, and operative rank were independent risks for reoperation. Early mortality in reoperations was 5.1%. Allograft endocarditis has occurred in 6 patients, giving an overall freedom of 94% at 25 years. Seven patients of the original cohort are known to be alive with their original allograft valve in situ, and of these the longest follow-up period is 29.8 years. The use of antibiotic-sterilized allografts for subcoronary aortic valve replacement confers low operative mortality and excellent long-term survival with durability matching any other nonmechanical device. Significantly reduced time-related risk of reoperation and excellent internal to external diameter ratio renders allograft aortic valve replacement especially ideal for smaller roots.

Intra-aortic Filtration is Effective in Collecting Hazardous Materials

Neurological complications after cardiac operations are mostly due to particle embolization. This case illustrates the embolic potential of any material. A 77-year-old lady underwent re-operation for homograft aortic regurgitation and mitral valve replacement. Intra-aortic filtration was used. After cardiopulmonary bypass the filter was found to have captured a pledget from a suture used to secure the mitral replacement device.

Percutaneous occlusion of a pseudoaneurysm evolving after homograft aortic valve and root replacement with the Amplatzer muscular ventricular septal defect occluder

of an early aggressive treatment was life saving. Compared with the scheduled device implantation in patients deteriorating on the waiting list, management of emergencies requiring circulatory support is still a challenging situation. We have developed in our unit a mobile kit of emergency circulatory support to deal with this problem. This ECLS has become a useful adjunct to our cardiac assist device program, allowing patient transfer and secondary implantation of a more long-term sophisticated device. As expected in this catecholamine-induced cardiomyopathy, the patient recovered after surgical resection of the tumor, but recovery is not so fast as to allow the use of an ECLS device alone, and implantation of a long-term device was mandatory.

Are allografts the biologic valve of choice for aortic valve replacement in nonelderly patients? Comparison of explantation for structural valve deterioration of allograft and pericardial prostheses

To compare explantation for structural valve deterioration in nonelderly patients after aortic valve replacement with stented bovine pericardial and cryopreserved allograft valves. From 1981 to 1985, 478 patients received pericardial prostheses during premarket approval; from 1987 to 2000, 744 patients received cryopreserved allografts. Mean age of patients receiving allografts was 49 +/- 12 years, and that of those receiving pericardial prostheses was 65 +/- 11 years; pericardial valves were used in 138 patients younger than age 60. Mean follow-up was 15 +/- 5.1 years for pericardial valves (4674 patient-years of follow-up) and 5.6 +/- 3.1 years for allografts (3892 patient years of follow-up). Multivariable hazard function methodology, age-group stratification, and propensity matching were used to compare age-specific explantation for structural valve deterioration. Ninety-five pericardial valves and 46 allografts were explanted, and structural valve deterioration was the mechanism of failure in 74% and 59%, respectively. The risk of structural valve deterioration increased with younger age at implantation for both allografts (P = .07) and pericardial valves (P < .0001), with a similar magnitude of effect in patients age 50 years or younger (P = .5), 50 to 60 years (P = .7), and greater than 60 years (P = .9) and in propensity-matched pairs (P = .2). Thus, pericardial valves were as durable as allografts at all adult ages. Structural valve deterioration is the most frequent cause of valve-related reoperation after both pericardial and allograft aortic valve replacement and is similarly age dependent, suggesting that pericardial valves may be appropriate for nonelderly as well as older persons.