Implantation of a composite bifurcated cryopreserved aorto-iliac-femoral homograft in a patient with Candida albicans endocarditis

A 35 year old woman, cocaine addict, suffered Candida albicans aortic valve endocarditis complicated with embolisation of infected vegetations in the distal abdominal aorta. She underwent successful staged aortic valve replacement followed by transaortic and transfemoral thrombectomy. One month later an arteriogram disclosed partial occlusion of the left iliac artery, bilateral aneurysmal degeneration of both iliac arteries and right iliac artery-right iliac vein fistula. She was operated again, performing re-laparotomy and re-exploration. A composite bifurcated cryopreserved homograft was implanted end-to-side between the infrarenal abdominal aorta, right external iliac artery and left common femoral artery. The right iliac artery-iliac vein fistula was obliterated with suture. The patient had an uneventful recovery but a relapsing arterio-venous fistula was diagnosed by arteriography. Three months later she underwent percutaneous transluminal closure of the reopened fistula. At present, 17 months after the implantation of the homograft, the patient is symptom-free, on antifungal agents and with arteriographic and clinical evidence of a well-functioning arterial homograft.     

Absent left pulmonary artery and double aortic arch in tetralogy of Fallot: reconstruction using homograft saphenous vein or iliac artery

Two cases of tetralogy of Fallot (TOF) with double aortic arch and absent left pulmonary artery are reported. Single-stage repair was performed using a left thoracotomy for division of the non-dominant arch followed by complete repair through a median sternotomy. In both patients, the left pulmonary artery was reconstructed using either a homograft saphenous vein or a homograft common iliac artery.     

Isolation of the left coronary artery ostium by an aortic cusp attachment: A rare cause of myocardial ischemia

A 34-year-old woman experienced a 3-month history of recurrent chest pain on exertion. Extensive investigation, including coronary angiography, revealed severe aortic incompetence with suspicion of single-vessel coronary disease. At operation the aortic valve was tricuspid but the left coronary cusp was adherent to the aortic wall, resulting in isolation of the left coronary artery with only a tiny communication with the aortic lumen. The three cusps were excised. An aortic valve replacement was performed with an aortic homograft. The postoperative course was uneventful and myocardial ischemia was totally relieved.     

Improved outcome with composite graft versus homograft root replacement for children with aortic root aneurysms.

OBJECTIVE: Review of surgical repair of aortic root aneurysms using composite graft or homograft in children. METHODS: A consecutive series of 34 children (mean age 10.8+/-5.4 years) who underwent elective aortic root replacement using composite graft or homograft from 1987 to 2003 (mean follow-up 5.7+/-3.7 years). RESULTS: Preoperatively, the aortic annulus and aortic root average z-scores were 4.1+/-2.2 and 9.4+/-4.7, respectively. Composite graft root replacement was performed in 22 patients, and cryopreserved aortic homograft root replacement in 12 patients. There was one perioperative death in the homograft group due to sudden cardiovascular collapse. There was one late death in the composite graft group due to acute aortic dissection, and two late deaths in the homograft root replacement group, one at 7 months postoperatively due to coronary artery thrombosis and one due to severe chronic myocardial dysfunction 5 years postoperatively. One patient who initially had a homograft died due to mechanical valve thrombosis following reoperative composite graft replacement. Five patients had reoperations at a median of 7.1 years after initial surgery. One patient in the composite graft group underwent arch replacement. There were no graft related reoperations after composite graft root replacement, but 4 patients in the homograft group had reoperative composite graft replacement. Predictors of reoperation included age at surgery, lower weight, and longer ICU time (P<0.05). CONCLUSIONS: In children with aortic root aneurysms, reoperation is more common after homograft root replacement than composite graft replacement. Composite graft root replacement provides more stable repair of the aortic root.     

Left ventricular mass reduction after aortic valve replacement: homografts, stentless and stented valves.

BACKGROUND: We studied the effect of four different types of prosthetic aortic valves on time course and extent of regression of left ventricular hypertrophy after aortic valve replacement for aortic stenosis. METHODS: Four groups of 10 patients each were randomly assigned to receive: (1) aortic homograft preserved in antibiotic solution at 4 degrees C, (2) Toronto stentless porcine valve, (3) Medtronic Freestyle stentless valve, or (4) Medtronic Intact aortic valve. The left ventricular mass index, effective orifice area index, and peak and mean transaortic gradients were measured by Doppler echocardiography before the operation and 8 months postoperatively. RESULTS: The hemodynamic performance indices were much better for the homograft and stentless valves than for the stented one. The absolute left ventricular mass index reduction was greater in the homograft group compared with the Intact (p = 0.0004) and Toronto (p = 0.007) groups. The extent of percent left ventricular mass index reduction was greater only in the homograft group versus Intact group (p = 0.005). The multilinear regression analysis showed that the only predictors of a larger percentage of left ventricular mass index reduction were the homograft type, a higher valve size index, and a higher preoperative left ventricular mass index. CONCLUSIONS: When a stentless or homograft aortic valve was used instead of a stented valve to replace a stenotic aortic valve there was more complete or at least faster regression of left ventricular hypertrophy. The hemodynamic performance of stentless porcine valves was similar to that of aortic homografts, nevertheless the aortic homografts preserved in antibiotic solution offered a faster regression of left ventricular hypertrophy during the same period of time.     

Aortic valve replacement in a patient with a patent internal thoracic artery graft

Myocardial protection in patients requiring a second open-heart surgical procedure after coronary artery bypass grafting, especially when there is a patent left internal thoracic artery graft to the left anterior descending coronary artery, remains controversial. We present the case of a patient in whom aortic valve replacement was undertaken 18 months after coronary artery revascularization. Unusual features included beating-heart aortic valve replacement with continuous retrograde coronary sinus perfusion and avoidance of dissection of the patent grafts, including the left internal thoracic artery and a saphenous vein graft.     

Iliac vein replacement with a descending aortic homograft

We describe successful replacement of the iliac vein using a descending aortic homograft. The ilio femoral system was avulsed after recannulation of the femoral vein during a third cardiac reoperation.     

Homograft aortic root replacement to correct infective endocarditis requiring seven open cardiac procedures

Infective endocarditis, presumably from a septic dental focus, affecting the aortic valve was seen as acute aortic regurgitation in a 20-year-old woman. Seven open cardiac procedures for replacement of the aortic valve and left ventricular outflow tract were performed over the subsequent 6 years. Aortic root replacement using a fresh antibiotic-sterilized homograft was performed as the last definitive operative procedure. This article is presented to highlight (1) the use of homograft aortic root replacement for extensive involvement of aortic valve and left ventricular outflow tract in cases of infective endocarditis and (2) the feasibility of multiple sternal reentries when indicated.     

Management of coronary artery compression caused by recurrent aortic root abscess

Extrinsic coronary artery compression is a rare cause of coronary ischemia. We report the case of a 61-year-old male who developed a recurrent aortic root abscess causing extrinsic coronary artery compression. This complication occurred one year after undergoing aortic valve replacement and pericardial patch exclusion of an aortic root abscess. Surgical correction required debridement of the abscess and replacement of the aortic root with a homograft resulting in resolution of coronary compression.     

Coronary artery stenosis following aortic valve replacement--a case report

A case with severe left main trunk (LMT) stenosis nine months after aortic valve replacement was presented. The patient, 57-year-old female, underwent aortic valve replacement with a tilting disk valve (Omnicarbon 21 A). Her postoperative course was uneventful, but angina pectoris developed after nine months. Coronary angiography was performed and revealed 99% LMT stenosis. Operation was performed with OTCA to LMT and with a saphenous vein graft to left anterior descending artery. Coronary artery stenosis following aortic valve replacement may be dangerous and it must be treated as soon as the diagnosis is established.     

Reoperation after insertion of aortic homograft as a right ventricular outflow tract

Three patients who developed pseudoaneurysm or stenosis of the right ventricular outflow tract after insertion of an aortic homograft between the right ventricle and the pulmonary artery presented the technical problems at reoperation of intimate adherence of the homograft to the sternum. Successful replacement of the defective aortic homograft was accomplished by sequentially employing peripheral venous and arterial cannulation, heart-lung bypass, hypothermia, circulatory arrest, sternotomy, right atrial cannulation, and resumption of bypass.     

Off-pump coronary artery bypass grafting via a left thoracotomy in a patient with left main trunk disease

We report a case of multiple coronary artery bypass grafting (CABG) via a left thoracotomy without cardiopulmonary bypass. A 54-year-old female with unstable angina pectoris associated with left main trunk disease underwent emergency CABG. Because the patient had a history of total arch and aortic root replacement due to type A aortic dissection, a left thoracotomy approach was selected. The proximal end of the Y-shaped saphenous vein graft was anastomosed to the left subclavian artery, rather than to the descending aorta, owing to the remaining aortic dissection. The distal end of the Y-shaped saphenous vein graft was anastomosed to the left anterior descending artery and the posterolateral branch without cardiopulmonary bypass. The postoperative course was uneventful. The results of this surgery seem to indicate that off-pump CABG via a left thoracotomy is a viable technique, especially for patients undergoing repeat CABG.     

Surgical glue resembling left atrial thrombus

A 41-year-old female with Down's syndrome and severe aortic regurgitation underwent homograft aortic root replacement. During the operation, surgical glue was applied which appeared to have inverted the left atrial appendage giving an appearance of a left atrial mass.     

Partial biventricular repair for double-outlet right ventricle with left ventricular hypoplasia

The presence of left ventricular hypoplasia in double-outlet right ventricle may increase the risk of biventricular repair and Fontan procedures. The hypoplastic left ventricle of an 11-year-old girl with complex double-outlet right ventricle was successfully incorporated in a modified biventricular repair by Dacron patch closure of the ventricular septal defect, diversion of venous return of the inferior vena cava to the mitral valve with an intraatrial baffle, insertion of a left ventricular apex to pulmonary artery valved aortic homograft, and diversion of residual systemic venous return directly to the lungs with a bidirectional superior vena cava to pulmonary artery shunt. Postoperatively, the systemic venous atrial pressure was 6 mm Hg and the pulmonary artery pressure was 14 mm Hg. This method is proposed as a partial biventricular repair hemodynamically superior to the Fontan procedure, although aortic homograft revision may be required in the future.     

Surgical Treatment of Prosthetic Valve Endocarditis with Homograft Aortic Valve Replacement

This article presents the University of Alabama experience with homograft aortic valve replacement for prosthetic valve endocarditis. Of 117 patients who have undergone homograft aortic valve replacement since 1981, there has been a total of 22 patients who underwent operation for endocarditis. Sixteen were isolated valve replacements, three combined with other procedures, and three were aortic root replacements. When placed in a setting of active endocarditis, there have been no reoperations for endocarditis of the homograft valve. Surgical techniques are presented for the freehand sewn homograft as well as aortic root replacement. Prosthetic valve endocarditis is a highly lethal event and when aortic valve replacement is advised in this setting, we believe a homograft aortic valve should be implanted whenever possible.     

Extended aortic root replacement with aortic allografts

Complex left ventricular outflow tract obstruction after operation for subaortic stenosis or with hypoplastic aortic anulus remains a challenge for pediatric cardiac surgeons. We have recently applied a new technique of extended aortic root replacement using a cryopreserved aortic allograft to treat two patients who had previously been operated on for subaortic stenosis and a third who had aortic stenosis with a hypoplastic aortic anulus. This new procedure combines the concept of aortoventriculoplasty with aortic root replacement and coronary artery reimplantation. The valved aortic homograft is used in place of an aortic valve prosthesis and the attached anterior mitral leaflet augments the interventricular septum to relieve the subvalvular left ventricular outflow tract obstruction. The coronary ostia are then reimplanted into the allograft and an anastomosis between the distal graft and the ascending aorta is completed. Allograft aortic tissue is then used to patch the right ventricular outflow tract. One patient had aortic stenosis with annular hypoplasia and did well after extended root replacement. Two patients had previous operations for subaortic stenosis before undergoing extended aortic root replacement. One required mediastinal exploration and drainage at 2 weeks for Serratia marcescens mediastinitis and bacteremia, but uncomplicated recovery followed. The other patient had complete heart block for 2 days, but normal sinus rhythm resumed and convalescence was benign. This modified technique with the aortic allograft was very helpful in treating these difficult problems, and the lack of mortality, limited morbidity, and good functional results are encouraging.     

Placement of a rapid deployment aortic valve in a patient with severely calcified aortic root homograft

Significant aortic calcification is a known sequelae of homograft aortic root replacement and creates a treatment challenge if these patients require cardiac reintervention. The standard surgical option for patients requiring an aortic valve replacement in the setting of a calcified aortic homograft has been a Bentall procedure, which is high-risk with extended cross-clamp, cardiopulmonary bypass and operative times. We present a patient with a severely calcified aortic homograft who underwent successful valve replacement using a rapid deployment aortic valve leaving the aortic root and arch intact and avoiding the more extensive redo aortic root replacement. Similar cases in the literature are rare.     

Left ventricular outflow tract false aneurysm late after aortic valve replacement

We describe an unusual case of left ventricular outflow tract (LVOT) pseudoaneurysm late after aortic valve replacement. A 77-year-old man, who had undergone aortic valve replacement with mechanical prosthesis 7 years ago, presented, asymptomatic, with a transesophageal echocardiography (TTE) diagnosis of a large cavitary mass arising behind the aortic wall. The orifice of the pseudoaneurysm was successfully surgically closed and the aortic root reconstructed with cryopreserved homograft.     

A successful surgical treatment of ascending aortic aneurysm, left common carotid artery aneurysm and left subclavian artery obstruction due to aortitis syndrome in active phase]

A 24-year-old female was admitted complaining of coldness of left upper extremity and pulsating tumor of the neck. She was diagnosed as ascending aortic aneurysm, left common carotid artery aneurysm and left subclavian artery obstruction due to aortitis syndrome on examinations. Although steroid treatment appeared to be effective in controlling inflammatory reaction, the left common carotid artery aneurysm increased in size and severe neck pain started. The risk of rupture was feared, and surgical intervention was carried out in spite of aortitis in active phase. The patient underwent surgery where aneurysmectomy and graft replacement for ascending aortic aneurysm, aneurysmectomy and graft replacement using autogenous saphenous vein for left common carotid artery aneurysm and bypass grafting for left subclavian artery obstruction were performed. The histology of resected specimens of aortic wall showed active aortitis. The postoperative course was uneventful and the patient was discharged on steroid.     

Aortic atresia with normal left ventricle: one-stage repair in early infancy

Successful one-stage repair of aortic atresia with a left ventricle was performed in a 6-week-old infant using a new technique. After patch enhancement of the hypoplastic aortic arch, the transected proximal pulmonary artery was directly anastomosed to the aortic arch. An intraventricular baffle established continuity between the left ventricle and neoaortic valve, and a homograft conduit was inserted between the right ventricle and pulmonary artery bifurcation.