SHOULD THE FREEHAND ALLOGRAFT BE ABANDONED AS A RELIABLE ALTERNATIVE FOR AORTIC-VALVE REPLACEMENT

Cryopreserved aortic allografts were used for aortic valve replacement in 80 patients between 1986 and 1994 (infracoronary in 46 and complet e root replacement in 34). Hospital mortality was 6.3% (5/80) with ail deaths occurring in the infracoronary group. Three of five deaths wer e in patients with endocarditis and valve ring abscess. Left ventricul ar-aortic mean pressure gradients across the allograft valves were sig nificantly lower for root replacement patients (mean, 9.0 +/- 6.9 mm H g versus 18.1 +/- 8.7 mm Hg for infracoronary patients) (p = 0.0001). No patient having root allograft replacement had early echocardiograph ic aortic insufficiency greater than grade 1 versus 28% of those havin g infracoronary implantations. Late aortic insufficiency of grade 2 or greater was seen in 46% of patients having infracoronary implantation versus 17% of patients having root implantation. Nine patients had ex plantation of an aortic allograft (eight infracoronary and one root). Reasons for explantation were as follows: endocarditis (three infracor onary, one root), technical (three infracoronary), undiagnosed idiopat hic hypertrophic subaortic stenosis (1 patient), and prolapsing infrac oronary leaflet (1 patient). Actuarial freedom from grade 3 and 4 aort ic insufficiency or explantation was 77% at 7 years for infracoronary implantations. We conclude that the infracoronary aortic allograft has an unacceptable frequency of late insufficiency and its use in this p osition should be abandoned. The substantial incidence of late endocar ditis in the infracoronary (freehand) aortic allograft was surprising. In aortic root allografts the progression to grade 2 valvular insuffi ciency (moderate) in 17% of patients by 22 months must be viewed with concern.