Aortic valve replacement: comparison of late survival between autografts and homografts

BACKGROUND: Autografts (AG) and homografts (HG) are currently considered the best choices for replacement of the diseased aortic valve in young adults, although few data exist comparing their late outcome. Nonhomogeneous populations and evolving operative techniques confound existing comparisons. METHODS: To help clarify these issues, we reviewed our results with 238 hospital survivors (aged 17 to 82 years) undergoing operation between 1986 and 1999. All operations were done as root replacements, and patients needing concomitant valve replacement were excluded. RESULTS: Mean age of the 145 AGs and 93 HGs was 35 +/- 13 years and 49 +/- 17 years, respectively (p < 0.001). Previous aortic valve replacement was done in 12 (8%) AG and 32 (34%) HG patients (p = 0.001), and active endocarditis was present at time of current operation in 10 (7%) AG and 25 (27%) HG patients (p = 0.001). Maximum follow-up was 12.2 years for AGs and 12.8 years for HGs. Late survival at 10 years was 77% +/- 11% for AGs and 67% +/- 9% for HGs (p = 0.13). Freedom from AG or HG degeneration at 10 years was 97% +/- 2% and 79% +/- 10% (p = 0.63). Freedom from valve-related complications at 10 years was 73% +/- 10% and 64% +/- 10% (p = 0.93), respectively. Freedom from all reoperations at 10 years was 88% +/- 5% for AG and 72% +/- 11% for HG (p = 0.67). CONCLUSIONS: Autografts and HGs have comparable late survival. The incidence of valve degeneration is low for both AG and HG up to about 8 years at which point there may be a trend toward an advantage for AG over the HG, suggesting benefit for the younger patient.     

Aortic valve replacement in cardiac ochronosis.

Two patients with generalized ochronosis developed cardiovascular symptoms related to cardiac ochronosis with aortic valvular stenosis. One patient with a transvalvular pressure gradient of 150 mm Hg underwent emergency aortic valve replacement. The other patient with a transvalvular pressure gradient of 96 mm Hg underwent successful elective aortic valve replacement. Cardiac ochronosis is a rare disease that might be encountered, with the typical signs, during an elective, planned cardiac operation. The most frequent presenting feature of this disease seems to be aortic valvular stenosis.     

Aortic valve replacement with frozen irradiated homografts : An 18-year experience

Between May 1968 and April 1981, 339 patients underwent isolated aortic valve replacement using frozen irradiated homografts. All the operations were carried out by the same surgeon (EJMW) using the same technique. Thirty-two patients were lost to follow-up at various stages and the long-term results of the remaining 307 patients are reported. Two hundred and thirty-four were males and 73 females. Their ages ranged between 10 and 75 years, with a mean age of 53. The dominant lesion was aortic stenosis in 195 cases (63.5%), aortic regurgitation in 68 (22.1%), and mixed aortic valve disease in 44 (14.3%). Early mortality was 8.8% and late mortality during the 5–18 year follow-up period was 49.6%. Re-operations for homograft failure were carried out in 112 patients (40%), with an early mortality of 25%. The results are compared with those of other major series using antibiotic sterilized homograft valves.     

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.     

Aortic assessment for cardiac surgical procedures

Aortic atheromatous disease is associated with stroke in both the ambulatory and perioperative setting. In addition to atheromatous deposits, a reduction in the compliance of the aorta takes place as elastin fibers are replaced by collagen fibers. Both of these distinct processes, termed atherosclerosis, can easily be measured using transesophageal echocardiography during cardiac surgery. A review of the literature demonstrates many studies supporting the benefit of transesophageal echocardiography examination of the aorta for reducing stroke following cardiac surgery, through modification of surgical techniques. There have also been attempts by surgeons to remove atheromatous lesions from the aorta during cardiac surgery. Unfortunately, these procedures currently have a high perioperative mortality. Finally, medical therapy such as warfarin or statins may help reduce the incidence of stroke following heart surgery.     

Aortic valve replacement in patients with previous cardiac surgery

BACKGROUND: Whether minimally diseased aortic valves should be replaced during other necessary cardiac operations remains controversial. Part of the decision-making process in that issue revolves around the risks of subsequent aortic valve replacement. This study evaluated the results of aortic valve replacement in patients following prior cardiac surgery. METHODS: From February, 1984 through December, 2001 first-time aortic valve replacement was performed in 132 consecutive patients who had previous cardiac surgery utilizing cardiopulmonary bypass. Of those patients 89 (67%) had aortic valve replacement at a mean of 8.3 years after prior coronary artery bypass grafting, and 43 (33%) had aortic valve replacement at a mean of 13.0 years after previous procedures other than myocardial revascularization. Hospital records of all patients were retrospectively reviewed. RESULTS: Early complications included operative mortality in six (6.7%) of the patients with prior coronary grafting and no mortality in the group with other prior operations. Patients having prior coronary grafting had more nonfatal complications than those with other previous procedures. CONCLUSIONS: Aortic valve replacement in patients following previous cardiac surgery can be accomplished with acceptable mortality and morbidity. Routine replacement of aortic valves that are minimally diseased during coronary artery bypass grafting may not be warranted.     

Aortic valve translocation for treatment of a deteriorated stentless valve

A 54-year-old woman was admitted to our hospital with recurrent chest pain for 1 month. She had a history of aortic root replacement with a stentless valve following aortic valve replacements done twice 12 years ago, and coronary artery bypass grafting 6 years ago. The stentless valve was implanted with the full-root technique. After admission, she was diagnosed with a saphenous vein graft aneurysm in the proximal anastomotic site and severe aortic regurgitation due to stentless valve deterioration. These lesions were successfully treated using aortic valve translocation. The advantage of this procedure is that it avoids dissection and removal of the stentless valve implanted using the full-root technique. Aortic valve translocation can be one of useful alternatives for stentless valve reoperation.     

The surgical risk in the treatment of arnold chiari malformations

Summary The authors describe a series of 26 patients (28 operations) with Arnold Chiari malformations who were admitted during a 4 year period.In 20 the malformation was treated by direct surgery on the posterior fossa. Seven were treated by ventriculoatrial shunting. An analysis of the surgical risks of each procedure is given. In addition a helpful guide in the choice of the proper surgical procedure is outlined.     

Medical and surgical treatment of venous malformations

Treatment of venous malformations (VM) is difficult as these lesions are ill defined and can infiltrate tissues. Moreover, no specific treatment related to their etiopathogenesis exists. Currently, VM can be treated conservatively or medically and, more aggressively with either sclerotherapy, or surgical resection. A multidisciplinary approach is needed to obtain the best result with minimal complications. Surgical resection, complete or partial, plays an important role in the treatment of symptomatic VM. In case of extensive VM, all techniques of plastic surgery are indicated.     

Aortic arch atheroma: stroke reduction in cardiac surgical patients

Cardiac surgery is increasingly performed on elderly patients with extensive coronary artery abnormalities who have impaired left ventricular function, decreased physiologic reserve, and multiple comorbid conditions. Considerable numbers of these patients develop perioperative neurologic complications ranging from subtle cognitive dysfunction to more evident postoperative confusion, delirium, and, less commonly, clinically apparent stroke. Magnetic resonance imaging studies have elucidated that a considerable number of patients have new ischemic brain infarcts, particularly after conventional coronary artery bypass graft surgery. Mechanisms of cerebral injury during and after cardiac surgery are discussed. Intraoperative transesophageal echocardiography and epiaortic scanning for detection of atheromatous disease of the proximal thoracic aorta is paramount in identifying patients at high risk from neurologic injury. It is important to recognize that our efforts to minimize neurologic injury should not be limited to the intraoperative period. Particular efforts should be directed to temperature management, glycemia control, and pharmacologic neuroprotection extending into the postoperative period. Preoperative magnetic resonance angiography may be of value for screening patients with significant atheroma of the proximal thoracic aorta. It is likely that for patients with no significant atheromatous disease, conventional coronary artery revascularization is the most effective long-term strategy, whereas patients with atheromatous thoracic aorta may be better managed with beating heart surgery, hybrid techniques, or medical therapy alone. Patient stratification based on the aortic atheromatic burden should be addressed in future trials designed to tailor treatment strategies to improve long-term outcomes of coronary heart disease and reduce the risks of perioperative neurologic injury.