Aortic root replacement in adolescents and young adults: composite graft versus homograft or autograft

Aortic root replacement (ARR) is a technically demanding procedure that can be performed using a variety of prosthetic devices. Root replacement in the young, but grown-up, patient poses unique problems in terms of the long-term outcome and active lifestyle that must be guaranteed by this operation. To identify the "ideal" substitute for ARR in the young, clinical results in teenagers and young adults (<35 years) operated on in the past two decades were reviewed.

Thirty-eight patients younger than 35 years underwent ARR between January 1980 and December 1996. Eighteen patients, aged 30+/-5 years, had ARR with composite graft (group 1), whereas 20 patients, aged 28+/-6 years, had ARR with aortic homografts or pulmonary autografts (group 2). Primary indication for the operation was aortic insufficiency with anuloaortic ectasia (12 of 18) in group 1 and aortic insufficiency with or without anuloaortic ectasia (16 of 20) in group 2. Urgent ARR was required in 3 (17%) group 1 patients and 1 (5%) group 2 patient (p = 0.01).

Operative deaths were 2 (11%) in group 1, caused by hemorrhage and low output, and none in group 2. There were 4 (25%) late deaths in group 1, caused by embolism (2), hemorrhage, and myocardial infarction, and 1 (5%) in group 2, caused by arrhythmia. Survival was 81% +/- 9%, and 55%+/-18% at 2 and 10 years in group 1 versus 94%+/-5% at 2 years in group 2 (p = 0.04). Freedom from valve-related events was 93%+/-6% and 62%+/-18% at 2 and 10 years in group 1 versus 100% at 2 years in group 2 (p = 0.02). Freedom from reoperation in group 1 was 75% +/- 22% at 10 years, whereas no reoperations were done in group 2. Seven (58%) group 1 patients versus 1 (5%) group 2 patient were on cardiac medications (p = 0.001), and 11 (92%) group 1 patients versus no group 2 patients were on warfarin therapy at follow-up. All survivors were back to school or prior employment.

Survival early after ARR does not differ depending on the type of prosthesis. Valve-related events are common, and reoperation may be needed late after ARR with composite grafts. Despite limited follow-up with biologic devices, the prevalence of complications with composite grafts makes homograft or autograft ARR preferable in adolescents and young adults.