Homografts in patients with combined disease of the aortic valve and the ascending aorta: An alternative to the classical Bentall procedure

Background and aim of the study: In patients with aneurysms or dissections of the ascending aorta and additional aortic valve disease, valve-containin g composite grafts are used in clinical routine. The study aim was to prese nt our experience with homografts for aortic valve replacement extended by a vascular prosthesis as an alternative to the classical Bentall procedure. Methods: Thirty consecutive patients (mean age 46 +/- 14 years) were includ ed in this study. Indications for valve replacement were aortic stenosis (n = 15), aortic insufficiency (n = 6), combined aortic valve disease (n = 6) , endocarditis of the native valve (n = 1), and endocarditis of a previousl y placed bioprosthesis (n = 2). The mean diameter of the ascending aorta wa s 5.6 +/- 0.5 cm; one patient had an acute dissection (diameter 4.4 cm). Fo r valve replacement, cryopreserved homografts (mean size 24 2 mm) were used in a mini-root technique, and the ascending aorta was replaced by collagen -coated vascular prostheses (mean diameter 28 +/- 3 mm). The size of the va scular prosthesis was adjusted to the diameter of the sinutubular junction of the implanted homograft. Follow up included annual clinical examinations , transthoracic echo cardiography and ultrafast computed tomography (CT) sc ans. Results: All patients survived surgery, and no deaths occurred during follo w up. None of the patients had postoperative anticoagulation, and no thromb oembolic events were noted. Follow up was complete, with an average 48 mont hs (range: 6 to 84 months). Doppler echocardiography revealed trivial to mi ld aortic regurgitation in nine patients postoperatively, with no deteriora tion during follow up. No pathologic pressure gradients over the aortic val ves were measured at Doppler echocardiography; the mean valvular orifice ar ea was 2.5 +/- 0.3 cm(2). At ultrafast CT, normal homograft anatomy includi ng the sinotubular junction, no calcifications, and no signs of annular dil atation were seen. In the patient who had surgery for acute endocarditis of the native valve, ultrafast CT revealed a small pseudoaneurysm below the l eft coronary artery, without need for reoperation. Conclusion: Short- and mid-term results show that cryopreserved homografts extended by small-sized vascular prostheses can be used safely for Bentall procedures in selected cases where the diameter of the aortic valve annulus is moderately dilated.