HOMOGRAFT REPLACEMENT OF THE AORTIC-VALVE AND ROOT AS A FUNCTIONAL UNIT

Homograft replacement of the aortic valve has inherent advantages for the patient in terms of decreased incidence of thromboembolism, endoca rditis, and anticoagulation-related complications. Limitations in its use stem from a significant incidence of postoperative aortic regurgit ation, related to difficulty with consistent commissural and sinotubul ar geometry when inserted in the subcoronary position. To minimize thi s complication, we used a homograft as a functional unit in 71 patient s between 1986 and May 1993, either as a root replacement (n = 58) or as an intraaortic inclusion cylinder (n = 13), There were 4 pulmonary and 67 aortic homografts. Mean age of the 16 female and 55 male patien ts was 42 +/- 19 years (range, 0.6 to 84 years). Thirty patients had p redominantly aortic regurgitation, 19 aortic stenosis, 18 mixed aortic valve disease, and 4 primary aneurysmal disease. Eighteen (25.4%) had infective endocarditis. Thirty-five patients (49%) had a previous ope ration on the aortic valve. Hospital mortality was 14.1% (10/71), 0% f or inclusion cylinders and 17.2% (10/58) for root replacements (p = no t significant). Recent follow-up was obtained in all hospital survivor s. Mean follow-up period was 35 months (range, 1 to 81 months). There were six late deaths, 1/13 for inclusion cylinders and 5/48 for root r eplacements. Actuarial survival at 5 years was 74.9% +/- 5.6%. Reopera tion was required in 3 patients (ail with root replacements), 1 for po stoperative endocarditis, 1 for left coronary ostial obstruction, and 1 for late onset of aortic dilatation and regurgitation (pulmonary hom ograft used as a root replacement). Two patients currently have asympt omatic greater than 2/4 aortic regurgitation. Freedom from significant aortic regurgitation was 88% +/- 7% at 6-year follow-up, More consist ent maintenance of the sinotubular and commissural geometry of the aor tic homograft may be achieved with the root replacement or the inclusi on cylinder techniques. This may reduce the incidence of postoperative aortic regurgitation and further benefit the patient by reducing the need for reoperation in the future.