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.     

Immediate and long-term results of valve replacement for native and prosthetic valve endocarditis

BACKGROUND: The objective of the present study was to compare current results of prosthetic valve replacement following acute infective native valve endocarditis (NVE) with that of prosthetic valve endocarditis (PVE). Prosthetic valve replacement is often necessary for acute infective endocarditis. Although valve repair and homografts have been associated with excellent outcome, homograft availability and the importance of valvular destruction often dictate prosthetic valve replacement in patients with acute bacterial endocarditis. METHODS: A retrospective analysis of the experience with prosthetic valve replacement following acute NVE and PVE between 1988 and 1998 was performed at the Montreal Heart Institute. RESULTS: Seventy-seven patients (57 men and 20 women, mean age 48 +/- 16 years) with acute infective endocarditis underwent valve replacement. Fifty patients had NVE and 27 had PVE. Four patients (8%) with NVE died within 30 days of operation and there were no hospital deaths in patients with PVE. Survival at 1, 5, and 7 years averaged 80% +/- 6%, 76% +/- 6%, and 76% +/- 6% for NVE and 70% +/- 9%, 59% +/- 10%, and 55% +/- 10% for PVE, respectively (p = 0.15). Reoperation-free survival at 1, 5, and 7 years averaged 80% +/- 6%, 76% +/- 6%, and 76% +/- 6% for NVE and 45% +/- 10%, 40% +/- 10%, and 36% +/- 9% for PVE (p = 0.003). Five-year survival for NVE averaged 75% +/- 9% following aortic valve replacement and 79% +/- 9% following mitral valve replacement. Five-year survival for PVE averaged 66% +/- 12% following aortic valve replacement and 43% +/- 19% following mitral valve replacement (p = 0.75). Nine patients underwent reoperation during follow-up: indications were prosthesis infection in 4 patients (3 mitral, 1 aortic), dehiscence of mitral prosthesis in 3, and dehiscence of aortic prosthesis in 2. CONCLUSIONS: Prosthetic valve replacement for NVE resulted in good long-term patient survival with a minimal risk of reoperation compared with patients who underwent valve replacement for PVE. In patients with PVE, those who needed reoperation had recurrent endocarditis or noninfectious periprosthetic dehiscence.     

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.     

复杂性感染性心内膜炎的外科治疗

目的评价瓣周脓肿、心肌脓肿以及瓣膜严重毁损等复杂性感染性心内膜炎手术治疗的近、远期疗效.方法回顾性分析1988年12月至2002年6月手术治疗的复杂性心内膜炎患者57例临床资料,均为原发性心内膜炎,其中感染侵犯主动脉瓣25例、二尖瓣16例、二尖瓣和主动脉瓣16例.术中发现瓣叶严重毁损32例、主动脉瓣周脓肿19例、主动脉根部环形脓肿导致左心室-主动脉连接破坏4例、二尖瓣后瓣环脓肿11例、心肌脓肿6例、瓣膜赘生物形成55例.脓肿清除后遗留残腔采用间断褥式缝合6例、自体心包片修补19例、牛心包片修补6例、聚四氟乙烯膨体补片修补4例;施行以带瓣管道作升主动脉根部替换和左、右冠状动脉移植术4例,主动脉瓣替换术21例,二尖瓣替换术16例,主动脉瓣及二尖瓣双瓣替换术16例.结果早期死亡6例(11%),死亡主要原因为低心输出量综合征、人造心脏瓣膜性心内膜炎和多脏器功能衰竭.随访4个月至14年,平均(5.93±0.20)年.晚期死亡5例,晚期主要并发症为人造瓣膜性心内膜炎.术后1年心功能恢复NYHA分组Ⅰ～Ⅱ级占96%(44/46);5年再手术免除率为(84±3)%,5年实际生存率为(61±9)%.结论复杂性心内膜炎局部组织破坏较多,应限期手术或急症手术,清创后残腔的处理是影响手术本身能否成功以及术后近、远期效果的关键.     

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.     

Indications for and results of cryopreserved homograft valve replacement

The cryopreserved aortic homograft valve is one of the most reliable of the stentless biological prosthesis if implanted properly. Due to the limited availability of homograft valves in Japan, the indications for their use are different from those in other countries. The first indication is active infective endocarditis in the aortic valve position, especially infection surrounding artificial implants. Another indication is for reconstruction of the right ventricular outflow tract during pulmonary autografting. Finally, aortic valve replacement in young women of childbearing age who wish become pregnant is an accepted indication. Since 1992, cryopreserved homograft valves have been used in Japan, and the number of surgeries performed with them has gradually increased. While efforts have been made to expand the homograft bank system in some areas, the supply remains insufficient. Because the demand for homografts is high, it is extremely important to establish a nationwide tissue bank system as soon as possible.     

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.     

Aortic root replacement using a homograft for recurrent valve endocarditis

Prosthetic valve endocarditis is a relatively rare condition associated with high mortality. Endocarditis affecting 2 successive mechanical valves at the aortic position has not, to the best of our knowledge, been described. We reported such a patient whose condition was further complicated by mitral regurgitation, pulmonary hypertension, worsening heart failure, and cardiac conduction abnormalities. Considering the failure of 2 previous mechanical valves, we conducted a homograft replacement of the aortic root with coronary reattachment. Mitral regurgitation was treated by annuloplasty. The patient's early postoperative course was uneventful and he was doing well 16 months after surgery. We discuss the overall treatment strategy for recurrent prosthetic valve endocarditis and potential homograft advantages.     

Aortic valve endocarditis with aortic root abscess cavity: surgical treatment with aortic valve homograft

Aortic valve endocarditis with an aortic root abscess cavity was treated by a modification of the standard technique of aortic homograft implantation in 3 patients. At a mean follow-up of 35 months, all 3 patients were well without reoperation or signs of aortic incompetence. This technique may, in some cases, be an alternative to the more complex procedure of homograft aortic root replacement with coronary reimplantation.     

Replacing the ascending aorta and aortic valve for acute prosthetic valve endocarditis: is using prosthetic material contraindicated?

BACKGROUND: The use of prosthetic material (rather than a homograft) for ascending aorta/aortic valve replacement (Bentall procedure) in cases of acute prosthetic valve endocarditis is controversial. We report favorable results using this technique almost exclusively (a homograft was used in only 3 patients with hematological problems) during a 12-year interval. METHODS: Twenty-eight patients (55 +/- 14 years; 22 male) underwent a Bentall procedure for acute prosthetic valve endocarditis between 1988 and 2000. Twenty-five patients had undergone previous aortic valve replacement (1 with concomitant mitral valve replacement, 4 with coronary artery bypass grafting), and 3 had had a previous Bentall operation. The median interval between initial surgery and reoperation was 13 months (range, 1 to 106). Sixty-eight percent of operations were urgent or emergencies. Ninety-three percent of patients had significant aortic regurgitation; complete annuloaortic dehiscence occurred in 71%, and in 57%, an abscess was found. Causative organisms were identified in 25 of 28 patients: Staphylococcus epidermidis (9), Staphylococcus aureus (7), Streptococcus viridans (6), Pseudomonas (2), and Legionella (1). RESULTS: Twenty-three patients had mechanical and 5 had biological valves implanted during the Bentall procedure. Hypothermic circulatory arrest was used in 64%. Hospital mortality was 11%: there was one intraoperative death, and two before discharge (one cardiac, one sepsis). Eighty-nine percent survived without stroke. During follow-up (median, 44.5 months; complete in 92%), 1 patient died of recurrent endocarditis at 4 months. CONCLUSIONS: These results indicate that prosthetic root replacement may be superior to use of a homograft for acute aortic prosthetic valve endocarditis, with only a 4% incidence of recurrent endocarditis and reoperation.     

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.     

Treatment of aortic valve endocarditis with the Ross operation

Objective: Standard treatment of patients with infective endocarditis is radical debridement and valve replacement, in cases with advanced pathology the treatment is usually root replacement with either a composite graft or a homograft. Enthusiasm for the use of the Ross operation in non-infective aortic valve disease is increasing, but use of the pulmonary autograft in the treatment of aortic valve endocarditis has been limited. The objective of this prospective study is to present the technique and results of our experience with aortic valve endocarditis treated with the Ross operation. Materials and methods: Since 1992 we have treated 35 patients (median age 41 years, range 6–71 years) having aortic valve endocarditis with a Ross operation. Twenty-four patients had advanced disease defined as pathology due to endocarditis extending beyond the valve cusps (13 patients) or prosthetic valve endocarditis (11 patients). Twenty-two patients had active disease at the time of surgery, and 12 had undergone one to four previous heart operations. Results: There were two operative deaths (5.8%), both related to severe disease with very advanced pathology and heart failure. Intraoperative echocardiography demonstrated no or trivial autograft insufficiency in all patients. There have been no late deaths. There has been one (probable) recurrent right-sided endocarditis in a drug addict during a follow-up period of 3–56 months. One patient has been reoperated on for homograft stenosis. Conclusions: We are enthusiastic about the use of the Ross operation in aortic valve endocarditis and in younger patients with advanced pathology, it is our preferred treatment modality. Following removal of the autograft, unparalleled exposure of the left ventricular outflow tract is obtained. Even in patients with very advanced pathology the left ventricular outflow tract is usually intact, allowing autograft implantation in the standard fashion. For selected patients with simple endocarditis, the Ross operation is an attractive option on its usual merits.     

Surgical management for active infective endocarditis: A single hospital 10 years experience

Objective  Surgical treatment of active infective endocarditis (IE) requires not only homodynamic repair, but also, special emphasis on the eradiation of the infection to prevent recurrence. This study was undertaken to examine the outcome of surgery for active infective endocarditis. Methods  One hundred sixty-four consecutive patients (pts) underwent valve surgery for active IE in Madani Heart Centre (Tabriz, Iran) from 1996 to 2006. Patients presenting with IE diagnosis (according to Duke Criteriaset) were eligible for study. Results  The mean age of patients was 36.3±16 years overall: 34.6±17.5 years for native valve endocarditis and 38.6±15.2 years for prosthetic valve endocarditis (p=0.169). Ninety one (55.5%) of patients were men. The infected valve was native in 112 (68.3%) of patients and prosthetic in 52 (31.7%). In 61 (37%) patients, no predisposing heart disease was found. The aortic valve was infected in 78 (47.6%), the mitral valve in 69 (42.1%), and multiple valves in 17 (10.3%) of patients. Active culture-positive endocarditis was present in 81 (49.4%) whereas 83 (50.6%) patients had culture-negative endocarditis. Staphylococcus aureus was the most common isolated microorganism. Ninety patients (54.8%) were in NYHA classe III and IV. Mechanical valves were implanted in 69 patients (42.1%) and bioprostheses in 95 (57.9%), including homograft in 19 (11.5%). There were 16 (9%) operative deaths, but there was only 1 death in patients that underwent aortic homograft replacement. Reoperation was required in 18 (10.9%) of cases. On multivariate logistic regression analysis, Staphylococcus aureus infection (p=0.008), prosthetic valve endocarditis (p=0.01), paravalvular abscess (p=0.001) and left ventricular ejection fraction less than 40% (p=0.04) were independent predictors of inhospital mortality. Conclusions  Surgery for infective endocarditis continues to be challenging and associated with high operative mortality and morbidity. Prosthetic valve endocarditis, impaired ventricular function, paravalvular abscess and Staphylococcus aureus infection adversely affect in-hospital mortality. Also we found that aortic valve replacement with an aortic homograft can be performed with acceptable in hospital mortality and provides satisfactory results.     

Surgical management of acute aortic root endocarditis with viable homograft: 13-year experience.

OBJECTIVE: Cryopreserved homograft valves have been used for acute infective aortic root endocarditis with great success but it is compounded by its availability in all sizes. The long-term clinical results of geometric mismatched homografts are not well defined and addressed. METHODS: Over a 15-year period (April 1986-June 2001), 816 patients presented with active infective endocarditis. One hundred and eighty-two of the patients aged between 9 and 78 years (mean: 51.0 +/- 1.13 years) consisting of 142 males and 40 females received homograft aortic valves. One hundred and ten patients were in NYHA functional class III and 72 in class IV and in cardiogenic shock. Of the patients, 2.7% suffered from septic embolism. One hundred and twenty-four (68.1%) patients presented with periannular abscesses and 58 (31.9%) with no abscess while 107 native valve (NVE) and 75 prosthetic valve (PVE) endocarditis were diagnosed preoperatively by transesophageal echocardiography (TEE) and confirmed intraoperatively. Freehand subcoronary implantation (FSCI) was used in 106 patients and root replacement in 76 patients. RESULTS: The operative death was 8.5% and for patients in NYHA functional class IV and in cardiogenic shock was 14.5%. Late mortality rate was 7.9%. Patient survival after discharge from hospital at 1 year was 97% and at 10 years was 91%, respectively. Thirty-one (22.1%) patients underwent reoperation after 1.7 years (mean) with two deaths (6.4%). Early (< or = 60 days) and late reinfection rate was 2.7 and 3.6%, respectively. Freedom from reoperation for matched and undersized homografts at 10-13 years was 85 and 55%, respectively. The univariate model identified undersized homograft (P=0.002), FSCI (P=0.09) and reinfection (P=0.0001) as independent risk factors for developing early and late valve dysfunction resulting in reoperation and homograft explant. CONCLUSION: Early aggressive valve replacement with homograft for active infective aortic root endocarditis with periannular abscesses is more successful than delayed last resort surgery. Homografts exhibit excellent clinical performance and durability with a low rate of reinfection, if properly inserted. Undersized homograft is an incremental risk factor for early and late reoperation.     

Aortic homograft implantation after Ozaki procedure: Case report

Introduction and importanceThe infective endocarditis incidence data for patients undergoing aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium (Ozaki procedure) are rare, and the optimal surgical treatment strategy remains unclear.Case presentationThis is the first case report of surgical treatment of infective endocarditis of aortic valve with cryopreserved homograft in an athlete with previously performed Ozaki procedure.Clinical discussionThe choice of homograft was dictated by the young age of the patient; professional activity as an athlete; refusal of anticoagulants and the need for wide excision of compromised tissues to mitigate potential risk of spread of infection as well as its recurrence.ConclusionThe use of the aortic homograft allowed us to radically remove the infected tissues and achieve hemodynamic characteristics similar to the native valve. This is probably the first case report of use of homograft to treat aortic valve endocarditis following Ozaki procedure.     

Acute endocarditis treated with radical debridement and implantation of mechanical or stented bioprosthetic devices

BACKGROUND: Operation for active infective endocarditis carries high mortality and morbidity rates, especially when the annulus is involved. Overall the literature favors the use of autograft and homograft valves because of better resistance to infection. In our clinic during the last 5 years we used an aggressive surgical approach to infective endocarditis in combination with implantation of mechanical or stented bioprosthetic devices. METHODS: From 1994 to 1999, 50 adults with aortic and/or mitral valve endocarditis underwent valve replacement. The median age of the 36 men and 14 women was 58 years (range, 17 to 78 years). All patients had active endocarditis at the time of operation. Native valve endocarditis was present in 48 patients and prosthetic valve endocarditis was present in 2 patients. The aortic valve was affected in 24 patients, the mitral valve in 21 patients, and both the aortic and mitral valves in 5 patients. Two of the patients with mitral endocarditis also had infection of the tricuspid valve. Annular destruction was present in 24 patients (48%). The patients were treated with radical excision of all infected tissue. The annular defects were closed, if possible, with direct sutures. Otherwise, a reconstruction was performed. Follow-up was 100% complete with a median follow-up period of 45 months (range, 6 to 66 months). RESULTS: The procedures were performed without lethal bleeding complications. Early mortality was 12% and the actuarial survival at follow-up was 80%. In none of the patients who died was death related to the prosthetic valve or recurrence of the endocarditis. Only 1 patient (2%) developed recurrence of the infective endocarditis and was reoperated with a Ross procedure. Three and a half years later the patient developed severe valve insufficiency of the autograft and was operated again with implantation of a mechanical device. CONCLUSIONS: Native and prosthetic valve endocarditis can be treated successfully with aggressive surgical debridement and implantation of mechanical or stented bioprosthetic devices with a low risk of recurrent endocarditis.     

Comparative analysis of isolated aortic valve replacement with fascia lata and homograft valves

Thirty-eight consecutive patients who underwent isolated replacement of the aortic valve with fascia lata in 1970 were compared with a similar series of patients undergoing homograft replacement of the aortic valve. These series were well matched in number, age sex of patients, symptomatology, valvular disease, electrocardiographic and roentegenographic changes, and preoperative cardiac catheterization data. The mean follow-up time was 73 months in the fascia lata series and 69.1 months in the homograft series, and all the post-operative survivors were reviewed. The early and long-term results were similar of the two series, and there was no statistical difference in the operative and late mortality, the incidence of early and late diastolic murmurs, valve failure necessitating valve replacement, infective endocarditis, thromboembolism, over-all survival, and survival with an intact valve. It is concluded that the long-term results of valve replacement using these two tissues, in the aortic position, are similar and there is little to choose between the two types of valves. If fascia lata, as we believe, is no longer acceptable as a satisafactory valve substitute, then homograft valves are not acceptable either.     

Surgical aspect of active infective endocarditis

Twenty patients with active infective endocarditis, 11 with native valve endocarditis (NVE) and 9 with prosthetic valve endocarditis (PVE), were treated surgically from 1975 through April 1987 at Kyushu University Hospital. The operative indications were congestive heart failure mainly due to massive aortic regurgitation in 18, periannular abscess in 6, major embolism in 5 and severe hemolysis in 3 patients. In the group of NVE, single aortic valve replacement was performed in 4 patients and multiple valve replacement in the remainder. One patient died early postoperatively from LOS. Two patients with recurrent infective endocarditis, which occurred within 60 days after previous prosthetic valve replacement, were operated subsequently as early PVE. All other patients became NYHA class I postoperatively except for one patient who died from thrombosed valve. In the group PVE, re-AVR was done in 3, re-MVR in five, double valve replacement in two and re-fixation of the prosthesis to the aortic annulus in one patient. Two patients with early PVE died from recurrent endocarditis late postoperatively. One of 7 patients with late PVE, who had suffered from myocardial and cerebral infarction before reoperation, died from multiple organ failure. There were 3 patients with perivalvular leakage due to late active PVE, whose preoperative signs of inflammation were negative or minimum. As recurrent perivalvular leakage due to persistent infective endocarditis might frequently occur in such cases, complete resection and debridement of infected foci should be emphasized.     

An experience with the Ross operation utilizing cryopreserved pulmonary homografts procured by and stored in our homograft valve bank

Eight patients, 4 males and 4 females ranging in age from 10 to 54 years (mean 27 +/- 13 years) underwent the Ross operation using a cryopreserved pulmonary homograft harvested by and cryopreserved in our institutional "Tissue Bank". Seven patients had a congenital bicuspid aortic valve and 3 patients had had healed infective endocarditis of the aortic valve. Four young female patients wanted to have a baby after operation. The Ross procedure was carried out utilizing aortic root replacement techniques in all patients. All patients survived and are currently in NYHA class 1, but 2 cardiac events occurred in 2 patients during the mean follow-up term of 29 +/- 19 months. The one was the anastomic stenosis between the homograft and distal pulmonary artery treated by balloon dilatation and the other was ventricular tachycardia eventually managed by the insertion of an ICD. Pulmonary autograft valve regurgitation is present in 3 patients, but it is not progressive up to the present time. Pulmonary homograft valves function well in all patients. The Ross operation for adolescents and young adults should become more popular along with more easy availability of homograft valves based upon the establishment of the "Homograft Valve Bank" system in Japan.     

Aortic root replacement with a mechanical valve and prosthetic conduit for the complicated degeneration of the ascending aorta resulting from infective endocarditis.

A 28-year-old man with infective endocarditis of the aortic valve underwent a course of antibiotic therapy, but developed severe aortic root deformity requiring aortic root replacement with a mechanical composite valve conduit. Of note, this patient had undergone a previous aortic valve operation for bicuspid valve stenosis, and indurations and fragility of the aortic root caused by the preceding operation may have contributed to subsequent aortic root deformity during the course of infective endocarditis of the aortic valve. Over the 7-year follow-up period, the patient showed no signs of recurrent infection or new cardiac events. For younger patients with endocarditis, the use of a mechanical valve and prosthetic conduit with sufficient surgical debridement and appropriate antibiotic therapy appears to be a safe and effective treatment strategy.