Nt. Kouchoukos et al., REPLACEMENT OF THE AORTIC ROOT WITH A PULMONARY AUTOGRAFT IN CHILDRENAND YOUNG-ADULTS WITH AORTIC-VALVE DISEASE, The New England journal of medicine, 330(1), 1994, pp. 1-6
Background. The optimal substitute for severely diseased aortic valves
in children and young adults is unknown. The use of a mechanical pros
thesis requires permanent treatment of the patient with anticoagulants
and is associated with thromboembolic and hemorrhagic complications.
Aortic-valve allografts and porcine bioprostheses, which do not necess
itate anticoagulant therapy, may deteriorate and have limited durabili
ty. Methods. We therefore evaluated the use of the autologous pulmonar
y valve (i.e., the patient's own pulmonary valve) and the adjacent pul
monary artery as a replacement for the aortic valve and aortic sinuses
in 33 patients. Five of the patients were from 8 to 16 years of age,
and 28 were from 20 to 47 years of age. The pulmonary valve and the ma
in pulmonary artery were used to replace the diseased aortic valve and
the adjacent aorta. The coronary arteries were detached from the aort
a and implanted into the pulmonary artery. The pulmonary valve and art
ery were replaced with a cryopreserved pulmonary allograft. Results. T
here were no deaths during follow-up of up to 48 months (mean, 21 mont
hs). There were no episodes of infective endocarditis, and no reoperat
ions on the aortic root were necessary. Also, there was no evidence on
echocardiography of progressive dilatation of the autografts. With co
lor-flow Doppler imaging, 22 patients were found to have only trivial
regurgitation or none, 9 patients to have mild regurgitation, and no p
atients to have moderate or severe regurgitation across the autograft
at the most recent follow-up visit. The mean peak velocity of flow acr
oss the autograft was 1.3 m per second (upper limit of normal, 1.8), i
ndicating the absence of stenosis. One patient required reoperation fo
r stenosis of the pulmonary allograft. Conclusions. Although the pulmo
nary-autograft procedure is more complex than simple aortic-valve repl
acement, it has been safely applied in selected patients, including yo
ung adults. Intermediate follow-up indicates satisfactory function of
the autografts, with no dilatation or progressive valvular regurgitati
on. Pulmonary-root autografts may thus be the best available substitut
e for diseased aortic valves in children and young adults.