Geometric mismatch between homograft (allograft) and native aortic root: a 14-year clinical experience

• Published in: European journal of cardio-thoracic surgery 2001-10, Vol.20 (4), p.835-841
• Main Authors: Yankah, A.C., Klose, H., Musci, M., Siniawski, H., Hetzer, R.
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Aged; Aorta, Thoracic - diagnostic imaging; Aorta, Thoracic - transplantation; Aortic allograft; Aortic Valve - diagnostic imaging; Aortic Valve - transplantation; Aortic Valve Insufficiency - diagnostic imaging; Aortic Valve Insufficiency - mortality; Aortic Valve Insufficiency - surgery; Aortic Valve Stenosis - diagnostic imaging; Aortic Valve Stenosis - mortality; Aortic Valve Stenosis - surgery; Biological and medical sciences; Child; Child, Preschool; Cryopreservation; Echocardiography, Doppler; Female; Follow-Up Studies; Geometric mismatch; Hemodynamics - physiology; Hospital Mortality; Humans; Infant; Male; Medical sciences; Middle Aged; Organ Preservation; Postoperative Complications - diagnostic imaging; Postoperative Complications - mortality; Reoperation; Risk Factors; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Survival Analysis; Transplantation, Homologous; Ventricular remodeling
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1016/S1010-7940(01)00885-5

Objectives: We evaluated the effect of homograft/native aortic root geometric matching and mismatching on valve survival and myocardial remodeling. Methods: Between January 1, 1987 and March 2000, a total of 292 patients, aged 1.5–78 years (mean, 46.2 years), underwent freehand subcoronary aortic valve (AVR; n=207) and root (ARR; n=85) replacement with matched and mismatched cryopreserved homografts. All patients had pre- and postoperative two-dimensional Doppler echocardiographic studies. Two-hundred and forty-three survivors, excluding children with complete data on sizing, were followed at a total follow-up time of 1269 patient-years. Seventy percent received matched and 30% received mismatched aortic homografts. The homograft valve sizes ranged from 19 to 28 mm. Results: Hospital death for elective first operation was 2.3%, and late death after a mean follow-up of 52 months was 7.9%. The patient survival at 14 years was 92±2%. By linear regression analysis, matched homografts were equal to or 1–2 mm less than the native aortic annulus (r2=0.73). The valve survival in patients with AVR and ARR was 72±4 and 80±8% at 14 years, respectively. The freedom from reoperation was 92±5, 77±4 and 48±10% at 14 years for matched, oversized and undersized homografts, respectively (P=0.001). The postoperative cardiac index of patients with 22 and 24 mm homografts was 3.8–4.1 l/m2, and there was a regression of the left ventricular mass and end-diastolic diameter (P=0.001). Conclusions: The aortic homograft offers an excellent long-term clinical result. A mismatched homograft is a risk factor for postoperative aortic incompetence, reinfection with pseudoaneurysmal formation and reoperation for the freehand subcoronary implantation technique during the first 7 years of the postoperative period. It is prudent therefore to avoid mismatched homografts and use rather a properly sized stentless xenograft if a root replacement is not indicated.