TY - JOUR
T1 - The valve-in-valve operation for aortic homograft dysfunction
T2 - A better option
AU - Khalpey, Zain
AU - Borstlap, Wernard
AU - Myers, Patrick O.
AU - Schmitto, Jan D.
AU - McGurk, Siobhan
AU - Maloney, Ann
AU - Cohn, Lawrence H.
N1 - Funding Information: The authors are thankful to Douglas Leonard and JustynMaund, for providing the spectropolarimetric data of SN 2004dt and SN 2012fr reported in this paper, and to Nando Patat, Lifan Wang and Craig Wheeler for useful discussions. SAS acknowledges support from STFC grant ST/L000709/1, RP by the European Research Council under ERC-StG grantEXAGAL- 308037, and WH and ST by TRR 33 'The Dark Universe' of the German Research Foundation (DFG). FKR acknowledges support by the DAAD/Go8 German-Australian exchange programme, and by the ARCHES prize of the German Ministry of Education and Research (BMBF). IRS was supported by the Australian Research Council Laureate Grant FL0992131. This work used the DiRAC Complexity system, operated by the University of Leicester IT Services, which forms part of the STFC DiRAC HPC Facility (www.dirac.ac.uk). This equipment is funded by BIS National E-Infrastructure capital grant ST/K000373/1 and STFC DiRAC Operations grant ST/K0003259/1. DiRAC is part of the National E-Infrastructure. This researchwas supported by the Partner TimeAllocation (Australian National University), the National Computational Merit Allocation and the Flagship Allocation Schemes of the NCI National Facility at the Australian National University. Parts of this research were conducted by the Australian Research Council Centre of Excellence for All-sky Astrophysics (CAASTRO), through project number CE110001020.
PY - 2012/9
Y1 - 2012/9
N2 - Reoperations on dysfunctional aortic homografts often require root reconstruction with coronary reanastomosis. This is associated with substantial perioperative morbidity and mortality. Resecting compromised aortic homograft valve leaflets and seating a new valve within the homograft annulus avoids root reconstruction and is a viable alternative. We retrospectively evaluated 50 patients undergoing reoperations on dysfunctional homografts between 1999 and 2011. Outcomes were compared between valve-in-valve (ViV) and aortic valve-prosthetic conduit (AVR-C) procedures. Twenty-eight patients underwent ViV, and 22 had AVR-C. Groups were similar in age, sex, and incidence of endocarditis and renal failure. Median time between homograft and index procedure was 8.5 years for AVR-C and 8 years for ViV patients (p = 0.93). Patients undergoing AVR-C had longer cardiopulmonary bypass (282 versus 151 minutes; p < 0.001) and cross-clamp (207 versus 106 minutes; p < 0.001) times and received significantly more intraoperative red blood cell transfusions than ViV patients (36.4% versus 7.1%; p = 0.014). Patients undergoing ViV had shorter intensive care unit stays (47 hours versus 67 hours for AVR-C; p = 0.049) and fewer postoperative red blood cell transfusions (21.4% versus 54.5%; p = 0.020). There were trends toward shorter ventilation times for ViV patients (6 hours versus 11 hours for AVR-C; p = 0.077), shorter postoperative length of stay (7 days versus 9 days; p = 0.092), and fewer readmissions (3.6% versus 19.0%; p 0.073). One operative mortality occurred in the AVR-C group. The strategy of replacing aortic valve leaflets in a failed calcified homograft, with a valve seated inside the annulus, is a safe alternative to root reconstruction. Preserving root architecture and coronary buttons facilitates shorter cardiopulmonary bypass and cross-clamp times, and directly impacts transfusions, intensive care unit time, hospital stay, and readmission rates.
AB - Reoperations on dysfunctional aortic homografts often require root reconstruction with coronary reanastomosis. This is associated with substantial perioperative morbidity and mortality. Resecting compromised aortic homograft valve leaflets and seating a new valve within the homograft annulus avoids root reconstruction and is a viable alternative. We retrospectively evaluated 50 patients undergoing reoperations on dysfunctional homografts between 1999 and 2011. Outcomes were compared between valve-in-valve (ViV) and aortic valve-prosthetic conduit (AVR-C) procedures. Twenty-eight patients underwent ViV, and 22 had AVR-C. Groups were similar in age, sex, and incidence of endocarditis and renal failure. Median time between homograft and index procedure was 8.5 years for AVR-C and 8 years for ViV patients (p = 0.93). Patients undergoing AVR-C had longer cardiopulmonary bypass (282 versus 151 minutes; p < 0.001) and cross-clamp (207 versus 106 minutes; p < 0.001) times and received significantly more intraoperative red blood cell transfusions than ViV patients (36.4% versus 7.1%; p = 0.014). Patients undergoing ViV had shorter intensive care unit stays (47 hours versus 67 hours for AVR-C; p = 0.049) and fewer postoperative red blood cell transfusions (21.4% versus 54.5%; p = 0.020). There were trends toward shorter ventilation times for ViV patients (6 hours versus 11 hours for AVR-C; p = 0.077), shorter postoperative length of stay (7 days versus 9 days; p = 0.092), and fewer readmissions (3.6% versus 19.0%; p 0.073). One operative mortality occurred in the AVR-C group. The strategy of replacing aortic valve leaflets in a failed calcified homograft, with a valve seated inside the annulus, is a safe alternative to root reconstruction. Preserving root architecture and coronary buttons facilitates shorter cardiopulmonary bypass and cross-clamp times, and directly impacts transfusions, intensive care unit time, hospital stay, and readmission rates.
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U2 - 10.1016/j.athoracsur.2012.04.019
DO - 10.1016/j.athoracsur.2012.04.019
M3 - Article
C2 - 22626756
SN - 0003-4975
VL - 94
SP - 731
EP - 736
JO - Annals of Thoracic Surgery
JF - Annals of Thoracic Surgery
IS - 3
ER -