The pulmonary autograft for aortic valve replacement in the young

Until recently, a mechanical prosthesis has been the substitute valve of choice for children and young adults who require aortic valve replacement. The preference for using mechanical valves in this group resulted from the discovery that porcine valves experienced accelerated structural degeneration in the young. Unfortunately, mechanical valves impose a constant risk of thromboembolism, resulting in a lifelong requirement for anticoagulant therapy. Thus, young patients with the potential for longer survival face a higher likelihood of having a thromboembolic or hemorrhagic event. To provide young patients with a durable replacement aortic valve that is not thrombogenic and does not require anticoagulation, some cardiac surgeons are transferring the patient's own pulmonary valve to the aortic position and replacing the pulmonary valve with a cryopreserved valve (a homograft) from a cadaveric donor. Long-term follow-up of the experience of Mr Donald Ross of London, England, who introduced this operation in 1967, indicates that the pulmonary autograft has the best event-free survival of any form of aortic valve replacement. The technical demands of this operation are greater than those for routine aortic valve replacement with a mechanical prosthesis; however, the pulmonary autograft can be performed at an acceptably low risk. As more experience is acquired with this technique, it may become the preferred procedure for aortic valve replacement in the young.