Aortic root replacement in adolescents and young adults: Composite graft versus homograft or autograft

Background. Aortic root replacement (ARR) is a technically demanding proced ure that can be performed using a variety of prosthetic devices. Root repla cement in the young, but grown-up, patient poses unique problems in terms o f the long-term outcome and active lifestyle that must be guaranteed by thi s operation. To identify the "ideal" substitute for ARR in the young, clini cal results in teenagers and young adults (<35 years) operated on in the pa st two decades were reviewed. Methods. Thirty-eight patients younger than 35 years underwent ARR between January 1980 and December 1996. Eighteen patients, aged 30 +/- 5 years, had ARR with composite graft (group 1), whereas 20 patients, aged 28 +/- 6 yea rs, had ARR with aortic homografts or pulmonary autografts (group 2). Prima ry indication for the operation was aortic insufficiency with anuloaortic e ctasia (12 of 18) in group 1 and aortic insufficiency with or without anulo aortic ectasia (16 of 20) in group 2. Urgent ARR was required in 3 (17%) gr oup 1 patients and 1 (5%) group 2 patient (p = 0.01). Results. Operative deaths were 2 (11%) in group 1, caused by hemorrhage and low output, and none in group 2. There were 4 (25%) late deaths in group 1 , caused by embolism (2), hemorrhage, and myocardial infarction, and 1 (5%) in group 2, caused by arrhythmia. Survival was 81% +/- 9%, and 55% +/- 18% at 2 and 10 years in group 1 versus 94% +/- 5% at 2 years in group 2 (p = 0.04). Freedom from valve-related events was 93% +/- 6% and 62% +/- 18% at 2 and 10 years in group 1 versus 100% at 2 years in group 2 (p = 0.02). Fre edom from reoperation in group 1 was 75% +/- 22% at 10 years, whereas no re operations were done in group 2. Seven (58%) group 1 patients versus 1 (5%) group 2 patient were on cardiac medications (p = 0.001), and 11 (92%) grou p 1 patients versus no group 2 patients were on warfarin therapy at follow- up. All survivors were back to school or prior employment. Conclusions. Survival early after ARR does not differ depending on the type of prosthesis. Valve-related events are common, and reoperation may be nee ded late after ARR with composite grafts. Despite limited follow-up with bi ologic devices, the prevalence of complications with composite grafts makes homograft or autograft ARR preferable in adolescents and young adults. (C) 1998 by The Society of Thoracic Surgeons.