The pulmonary autograft: results and left ventricular function

From June 1991 through January 1996, 60 patients (mean age, 30 years) underwent aortic valve replacement with pulmonary autografts. Indications for operation were aortic stenosis in 31 patients, aortic incompetence in 27 patients, and endocarditis in 2 patients. Twenty-four patients were congenital patients (median age, 10 years; range, 5 months to 27 years) with aortic incompetence in 17, isolated aortic stenosis in 5, and small stenotic prostheses in 2. Transthoracic echocardiography was performed preoperatively in all patients and serially after surgery with the aims of measuring aortic and pulmonary annuli, to evaluate gradients and incompetence, and to study the left ventricular (LV) function. Intraoperative transoesophageal echocardiography was routinely used. Complete root replacement was performed in 46 patients, intraluminal cylinder in 11 patients, and subcoronary implantation in 3 patients. One patient died in the early postoperative period (2%). There was no late death. All survivors remained in New York Heart Association class I and were free of complications and medications. No gradient nor any significant aortic incompetence could be demonstrated. On the pulmonary outflow tract, 4 patients had gradients between 20 and 40 mm Hg as calculated on echocardiography. In the 17 congenital patients with significant aortic incompetence before surgery, the LV function was followed up prospectively. The end-diastolic LV dimension (EDD) diminished drastically from 2 +/- 3.4 SD above normal to -0.63 +/- 2.4 SD at 1 week postoperatively (D10), to reach normal values 1 to 3 months after surgery. LV mass remained abnormal at D10 (from 4.7 +/- 3.3 SD to 5.3 +/- 3.8 SD) and diminished more progressively to reach normal values (0.14 +/- 1.4 SD) at 3 months. This resulted in a significant decrease of end-systolic wall stress (-3.6 +/- 2.1 SD) and in a hyperdynamic function in the immediate postoperative days except in 2 patients. These 2 patients were characterized preoperatively by more severely dilated LV (EDD 5.3 +/- 0.03 vs 1.6 +/- 3 SD) with decreased LV wall thickness (EDW) (1.19 +/- 0.7 vs 3.44 +/- 1.9 SD), decreased EDW/EDD (0.14 +/- 0.06 vs 0.2 +/- 0.06), and a decreased velocity of shortening. Unlike the other 15 patients, the LV function did not recover completely at mid-term follow-up in those 2 patients. The pulmonary autograft gives excellent results with low mortality and no morbidity. It suppresses completely the abnormal loading conditions of the LV, resulting in a complete recovery of LV function in most patients.