PULMONARY AUTOGRAFT VALVE-REPLACEMENT IN THE DILATED AND ASYMMETRIC AORTIC ROOT

Pulmonary autograft aortic valve replacement is the only technique for implantation of a biologic, vital and thus nondegenerating valve. The technique of root replacement overcomes problems of asymmetric aortic roots and reduces the risk of malalignment, but bears the risk of dil atation. We have performed pulmonary autograft aortic root replacement in 20 patients (mean age 22 years, range 5-38). Twelve presented with aortic incompetence, 3 with stenosis and 5 with combined defects. Ini tially roots were implanted just supraannularly with two running sutur e lines. As the neo-aortic roots gradually dilated, we started to impl ant autografts intraannulary, but still one valve dilated and aortic i ncompetence (AI) increased from grade I to II. Consequently the remain ing aortic wall was wrapped around the new root and the composite subs equently was reinforced by a circular absorbable mesh. In addition, th e aorta and pulmonary valve were exactly sized and the aortic root was reduced by commissuroplasty stitches up to 6 mm in diameter in seven cases. The ventricular size decreased in all patients 10 days after su rgery, the left ventricular end-diastolic diameters (LVEDD) from 58 +/ - 12 to 52 +/- 10 mm (P = 0.0002; paired t-test) and left ventricular end-systolic diameter (LVESD) from 41 +/- 12 to 36 +/- 10 mm (P = 0.00 8), but the contractility did not change significantly (fractional sho rtening from 31 +/- 9% to 30 +/- 9%). The diameter of the new aortic r ing increased for the supraannular position but size matching and the intraannular valve position reduced the new ring size significantly (P = 0.001). The postoperative AI averaged 0.8 +/- 0.6. We observed two significant aortic insufficiencies developing or deteriorating postope ratively. Both were caused by leaflet perforations and cured successfu lly by patch valvuloplasty. Aortic root replacement with pulmonary aut ograft is a safe and potentially durable means of replacing diseased a ortic valves. Needle punctures of the thin leaflets may develop into s ignificant perforations.