Aortic reoperation after freestanding homograft and pulmonary autograft root replacement

Human allografts and pulmonary autografts offer many advantages as an aortic valve and root substitute. The progressive degeneration of the aortic allograft and the pulmonary autograft has been seen as an important disadvantage, and the need for a reoperation has been perceived as challenging and risky for the patients.

Between March 1992 and October 2009, 53 consecutive patients (mean age 50 ± 13 years; 38 male), who had a previous aortic root replacement, underwent redo surgery for failure of the aortic homograft (n = 42) or the pulmonary autograft (n = 11). The median follow-up (available for 47 of 51 patients) was 44 months.

Structural valve deterioration was the main indication for reoperation on the homograft (86%), with an earlier presentation in patients who received homografts from donors more than 55 years old. Failure of the pulmonary autograft occurred primarily because of severe aortic regurgitation predominantly due to dilation of the autograft (n = 5) and autograft valve prolapse (n = 5). The total in-hospital mortality was 3.8% (n = 2). No deaths occurred among patients who previously underwent a Ross procedure. The course was complicated in 25 cases (48%). The cumulative 1-year, 5-year, and 8-year survival rates were 92%, 90%, and 77%, respectively. No late deaths were encountered after reoperation on the pulmonary autograft (maximum follow-up 218 months). Freedom from reoperation (excluding early in-hospital operation) for recurrent aortic valve or root pathology was 97% at 8 years.

Reoperation after freestanding homograft and pulmonary autograft root replacement can be accomplished safely. The total postoperative morbidity rate is still high.