Reoperative aortic valve operation after homograft root replacement: surgical options and results

The surgical options available and the associated operative risks for repeat aortic valve replacement after free-standing homograft root replacement with reimplantation of the coronary arteries are as yet undefined. We therefore reviewed our experience with repeat aortic valve replacement between January 1976 and July 1994 and identified 22 such procedures performed on 21 patients after homograft or autograft root replacement. Reoperation was indicated for structural deterioration in 16 and for bacterial endocarditis in 6 patients. Associated procedures were undertaken in 5 patients, and 4 procedures were performed emergently. Significant calcification of the homograft wall was noted in over half of all patients. There were no coronary ostial complications. In 13 patients new valves were inserted within the previous root: 9 mechanical valves and 4 subcoronary homografts. In 9 patients the root was re-replaced. The mean cross-clamp time was 85 (+/- 20) minutes and mean cardiopulmonary bypass time was 123 (+/- 32) minutes. There were no early deaths and 5 late deaths. Two patients required reoperation for bleeding and 2 experienced low cardiac output syndromes postoperatively. Univariate analysis failed to identify any variables predictive of outcome. We conclude that repeat aortic valve replacement after homograft root replacement, even in the presence of significant calcification, can be undertaken with an acceptable operative risk and should not be delayed until irreversible ventricular dysfunction has occurred. The same options available at initial valve replacement may be employed at reoperation, although extensive calcification mandates repeat root replacement.