Medium-term results of aortic valve replacement with cryopreserved homograft valves: importance of a domestic homograft valve bank

There are advantages to using aortic homografts as aortic valve replacements (AVR), particularly in patients with complex infective endocarditis. To determine the importance of a domestic homograft valve bank, our 23 surgical cases of homograft-AVR were reviewed. Since 2000, the Tissue Bank of the National Cardiovascular Center has supplied 23 aortic homograft valves for the treatment of complex aortic valve endocarditis. Fourteen of 23 patients had prosthetic valve endocarditis and 20 patients had an aortic annular abscess. The early mortality rate was 17% (4 patients), in all of whom prosthetic valve replacement had been performed previously. No recurrent endocarditis and no recurrent aortic regurgitation were noted at medium-term follow-up. An aortic homograft valve is the conduit of choice in cases of infective endocarditis and the importance of a domestic homograft valve bank should be recognized.     

Immediate tricuspid valve replacement for endocarditis. Indications and results

Tricuspid valve excision for tricuspid endocarditis in addicts is recommended to avoid early reinfection, continued sepsis, and late reinfection because of the resumption of intravenous drug abuse. Valvectomy is allegedly well tolerated hemodynamically by some, but it leads to heart failure in at least a third of patients. In our experience in 10 addicts with staphylococcal endocarditis who had failed to respond to antibiotic therapy, tricuspid valve replacement allowed all 10 to leave the hospital free of infection and free of heart failure. Resumption of drug addiction in three led to septic death, but not necessarily to tricuspid reinfection. Two returned to jobs requiring a high level of physical labor and tolerated this without difficulty. We find no need to follow the practice of tricuspid valve excision for tricuspid endocarditis in addicts. Those who refrain from drug abuse are well served by valve replacement. Those who do not are doomed with or without a tricuspid valve.     

Short-term result of aortic valve replacement with cryopreserved homograft valve in the University of Tokyo Tissue Bank

The short-term results after aortic root replacement with 11 cryopreserved aortic homografts was examined. Since 1998, the University of Tokyo Tissue Bank has supplied 11 aortic homograft valves. Nine of the recipients were male, and the average age was 51.2 years. Nine out of 11 patients had suffered from a serious condition of native or prosthetic valve infectious endocarditis. All of the patients underwent aortic root replacement, and the blood type between the patient and the homograft was matched in 8 of the patients. Only 1 patient died (9.1%) in the short-term due to sepsis. The preoperative degree of aortic valve regurgitation in all of the cases was third or fourth while the regurgitation disappeared after the operation in all of them. Thinking of the serious condition of our cases preoperatively, the 9.1% operative mortality was quite acceptable. Long-term follow-up is necessary to estimate the quality of the homografts.     

Mitral valve replacement with homograft

The technique for replacement of the mitral valve with a mitral valve homograft is described. Principles include side-by-side approximation of the papillary muscles using multiple stitches of fine monofilament suture, direct attachment of the annulus of the mitral homograft to the annulus of the patient, and support of the repair by remodeling annuloplasty ring.     

Tricuspid bioprosthesis replacement with cryopreserved mitral homograft.

We report the case of replacement of a dysfunctional tricuspid Hancock bioprosthesis by a cryopreserved mitral homograft. Tricuspid bioprosthesis was approached on a beating heart. The mitral homograft was orientated so as the anatomic anterior leaflets corresponding and a semi rigid prosthetic ring was inserted. At 1 year follow-up, the patient's clinical condition and echocardiographic results were satisfactory.     

Viable cryopreserved aortic homograft for aortic valve endocarditis and annular abscesses

Six consecutive patients with active aortic valve endocarditis, including 2 with extensive subannular aortic root abscess, were successfully treated with viable cryopreserved homograft aortic valve replacement. Two patients required extensive aortic root reconstruction with an appropriately trimmed aortic homograft to cover large abscess cavities. All patients showed resolution of infection with no perioperative mortality or clinically significant morbidity. Three patients had a minor degree of aortic insufficiency on postoperative echo-Doppler study. On follow-up at 6 to 48 months, all patients were in New York Heart Association functional class I. The resistance of the unstented homograft to infection makes it an attractive choice for patients requiring aortic valve replacement for active endocarditis. The results of surgical intervention in patients with extensive aortic root involvement may be further improved by the flexibility afforded by the homograft to be "custom-fit" to the abnormal aortic root and the ability to achieve secure abnormal aortic root and the ability to achieve secure valve fixation without use of prosthetic material.     

Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis

Background. There are advantages to using homografts and autografts as aortic valve replacements, particularly in patients with infective endocarditis. To better define these advantages, we reviewed our 13-year experience with the surgical management of infective endocarditis involving the aortic valve and root.

Methods. From 1986 through 1998, 81 adults with aortic valve endocarditis underwent valve replacement (AVR). The mean age of the 65 men and 16 women was 44 ± 14 years. Sixty-three (78%) patients had active endocarditis at the time of operation. Non-native valve endocarditis was present in 29 (36%) patients, in 9 of whom the infection was a recurrence. Aortic valve replacements were performed with 46 homografts (homo-AVR), 25 autografts (Ross-AVR), and 10 prosthetic valves (prosth-AVR). Among Ross-AVR and homo-AVR patients, 11 required mitral valve replacement or repair (homo-Ross DVR). Follow-up was 90% complete within 2 years of the end of the study with a mean of 3.7 ± 3.4 years.

Results. Early mortality was 16% (13 of 81 patients). This was 12% (3 of 25 patients) for Ross-AVR, 17% (8 of 46 patients) for homo-AVR, and 20% (2 of 10 patients) for prosth-AVR. Overall late mortality was 10% (7 of 68 patients) with a valve-related late mortality of 7% (5 of 68 patients). Actuarial survival at 5 years was 88% ± 9% in Ross-AVR, 69% ± 11% in homo-AVR, and 29% ± 22% in prosth-AVR (p = 0.03). Endocarditis recurred in 12.5% (1 of 8 patients) with prosth-AVR and 3% (2 of 60 patients) in homo-Ross AVR.

Conclusions. Valve replacement in the presence of native and prosthetic endocarditis remains a formidable challenge. Autografts and homografts are the preferred replacement aortic valves for these patients even if concomitant mitral valve replacement is required, and risk of valve-related death or recurrent endocarditis is low at medium-term follow-up.     

Results of homograft aortic valve replacement for active endocarditis

Since July 1985, cryopreserved homograft prostheses have been used for aortic valve replacement in 10 patients, aged 2 to 77 years, with active endocarditis. Five patients had positive bacterial cultures from excised valves, and all had clinical findings of uncontrolled infection while receiving appropriate antibiotics. Homograft valves (four) or valved conduits (six) were implanted for treatment of sepsis (6 patients), congestive heart failure (3) or recurrent emboli (1 patient), and complicating native (5 patients) or prosthetic valve (5) endocarditis. Staphylococci (6 patients), streptococci (3), and Candida (1) were infecting organisms. Preoperatively, Doppler echocardiography showed aortic regurgitation in all patients. At operation, 9 patients had gross vegetations, 9 had single or multiple abscess cavities, and 5 had pericarditis. Complex reconstruction of the aortic valve and annulus with homograft conduits was necessary in 6 patients (3 with previous aortoventriculoplasty). Two early deaths (ventricular failure, perioperative stroke) occurred. Mean follow-up of all operative survivors was 2.1 years (range, 0.6 to 3.6 years), and one late death resulted from arrhythmia. Homograft valve regurgitation increased in 1 patient, and 7 late survivors are asymptomatic. No patient has had recurrence of endocarditis. We conclude that cryopreserved homograft aortic valve/root replacement is an effective method for management of active endocarditis complicated by annular destruction.     

Mitral valve replacement with stored inverted pulmonary homograft valve

The fate is described of 11 patients who had a stored pulmonary valve homograft mounted on a frame or in a Dacron jacket used for mitral valve replacement. Mitral regurgitation due to holes in the attenuated cusps occurred in nine by one year, requiring re-operation or causing death. Only one patient remains well with moderate mitral regurgitation after two years.     

Miliary tuberculosis following homograft valve replacement.

Postoperative septicaemia with infective endocarditis is a recognized complication of open-heart surgery, in particular homograft or prosthetic replacement of cardiac valves. Several infective organisms, both bacterial and fungal, have been incriminated but infection due to tubercle bacilli has not, to our knowledge, been reported. The clinicopathological features of this condition are discussed. During a five-year period, over 800 homograft replacements in the aortic and/or mitral positions have been performed at Harefield Hospital. Seven cases of miliary tuberculosis following homograft valve replacement are descrbied here. In three, there was a past history suggestive of tuberculosis infections but necropsy failed to reveal any caseous or other tuberculous lesion apart from recent miliary tuberculosis. Vegetations on the homograft valves contained microcolonies of acid-fast bacilli in most cases. Tubercle bacilli of the human type were recovered by culture or guinea-pig inoculation in six of the seven cases, and in three the diagnosis was established during life; two of these survived on antituberculosis chemotherapy. The onset of symptoms varied from a few weeks to 12 months after operation. The main presenting symptom was intermittent pyrexia. In two patients the diagnosis was made on radiological and clinical grounds and in both, tubercle bacilli were grown from drill biopsy specimens of lung tissue. The source of infection was presumed to be the homograft valves contaminated in the postmorten room. The antibiotic mixture used in the sterilization of the homografts was not effective against tubercle bacilli.