REPLACEMENT OF THE AORTIC ROOT WITH A PULMONARY AUTOGRAFT IN CHILDRENAND YOUNG-ADULTS WITH AORTIC-VALVE DISEASE

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.