Outcome after homograft redo operation in aortic position.

OBJECTIVE: Since 1992, homografts have been implanted in our institution. After initial sub-coronary implantation of the homograft, our preferred technique for aortic-valve replacement with homografts became root replacement, which poses a surgical challenge whenever redo procedures are necessary. The aim of the present study was to evaluate the outcome after homograft redo surgery, based on prospective data from the biggest patient cohort in Germany for this procedure. METHODS: Between May 1992 and August 2009, 363 adult patients underwent aortic-valve replacement with homografts in our cardiac surgery department. Homograft replacement was indicated in 90 of these 363 patients due to degenerative or infective conditions, and these were analysed. RESULTS: In these 73 male and 17 female patients (mean age at redo operation 62.0 years), homograft explantation was necessary due to infection (n = 14) or degeneration (stenosis n = 19, regurgitation > II° n = 57). Mean time between homograft implantation and redo operation was 8.4 ± 3.6 years (range 0.0-15.5 years). Redo valve replacement through the aorta/homograft was done in 86 cases (valve into homograft wall = 80, total replacement of the homograft = 6) and trans-apical homograft replacement with an Edwards Sapien® Trans-catheter valve in four. Thirteen additional procedures were performed: bypass surgery (n = 1), mitral-valve repair (n = 6), replacement of the ascending aorta (n = 5) and tricuspid-valve repair (n = 1). Thirty-day mortality was 8.9% (n = 8, all of these patients presented with a homograft infection; five patients had a homograft reinfection). Survival rates after 1 and 5 years were 86.0% and 77.4%, respectively. CONCLUSIONS: The risk for a redo procedure after aortic-valve replacement with a homograft seems to be acceptable when compared with other prostheses. Mortality was, however, elevated in patients with a homograft infection. Trans-apical procedures are safe and feasible and might be our preferred technique for the future. Valve infections still remain a contraindication for trans- apical procedures.

Pulmonary homografts for aortic valve replacement: long-term comparison with aortic grafts.

OBJECTIVE: The use of homografts for aortic valve replacement (AVR) is an alternative to mechanical or biological valve prostheses, especially in younger patients. This retrospective comparative study evaluated our single-center long-term results, with a focus on the different origins of the homografts. METHODS: Since 1992, 366 adult patients have undergone AVR with homografts at our center. We compared 320 homografts of aortic origin and 46 homografts of pulmonary origin. The grafts were implanted via either a subcoronary technique or the root replacement technique. We performed a multivariate analysis to identify independent factors that influence survival. Freedom from reintervention and survival rates were calculated as cumulative events according to the Kaplan-Meier method, and differences were tested with the log-rank test. RESULTS: Overall mortality within 1 year was 6.5% (21/320) in the aortic graft group and 17.4% (8/46) in the pulmonary graft group. In the pulmonary graft group, 4 patients died from valve-related complications, 1 patient died after additional heterotopic heart transplantation, and 1 patient who entered with a primary higher risk died from a prosthesis infection. Two patients died from non-valve-related causes. During the long-term follow-up, the 15-year survival rate was 79.9% for patients in the aortic graft group and 68.7% for patients in the pulmonary graft group (P = .049). The rate of freedom from reoperation was 77.7% in the aortic graft group and 57.4% in the pulmonary graft group (P < .001). The reasons for homograft explantation were graft infections (aortic graft group, 5.0%; pulmonary graft group, 6.5%) and degeneration (aortic graft group, 7.5%; pulmonary graft group, 32.6%). CONCLUSION: Our study demonstrated superior rates of survival and freedom from reintervention after AVR with aortic homografts. Implantation with a pulmonary graft was associated with a higher risk of redo surgery, owing to earlier degenerative alterations.

Homograft implantation for aortic valve replacement since 15 years: results and follow-up.

BACKGROUND: The use of homografts in aortic valve replacement is an alternative to other prostheses and has been established in our department for 15 years. METHODS: Since 1992, 360 homografts (HG) have been implanted in adult patients (mean age 51.6 years, 72.8% male). Prospective follow-up was done on an annual basis. RESULTS: Thirty-day mortality was 5.0% (n = 17); after 5, 10, and 15 years, survival was 88.3%, 84.6%, and 76.0%, respectively. Out of 39 late deaths, 11 were valve-related (10 HG infections, 1 aortic aneurysm). Freedom from reoperation was 99.4% 1 year after operation; after 5, 10, and 15 years it was 94.1%, 78.2%, and 67.3%, respectively. Indications for HG explantation were graft infections (n = 20), calcification (n = 16), regurgitation > grade II (n = 17), perforation (n = 8), and paravalvular leakage (n = 1). Eleven transitoric ischemic attacks, 2 strokes, and 1 cerebral bleeding event were recorded. In echocardiography, the transvalvular pressure gradient changed from 10.55 to 15.02 (P = .004), 19.9 mmHg (P = .056), and 37 mmHg (not applicable) after 5, 10, and 15 years, respectively. Mean HG regurgitation was grade 0.49 before discharge and increased to 1.0 (P < .001), 0.91, and 2.5 after 5, 10, and 15 years, respectively. Ejection fraction increased from 61.9% to 64% after 5 years and to 66% after 10 years (P = .021) and then decreased to 63.5% after 15 years. CONCLUSIONS: Comparing HG with other valve prostheses, survival and graft durability seem to be confirmed. They are vulnerable to infections. The hemodynamic performance is good, and hemorrhagic or thrombo-embolic events are rare.

Acute profound thrombocytopenia after treatment with tirofiban and off-pump coronary artery bypass grafting.

The glycoprotein IIb/IIIa (GP IIb/IIIa) receptor antagonists prevent platelet aggregation and thrombus formation, improving outcomes of patients with acute coronary syndrome. Therapy with these agents may lead to bleeding complications and thrombocytopenia, challenging the perioperative management of patients undergoing coronary surgery. We report the successful management of an acute profound thrombocytopenia after urgent off-pump coronary surgery in a patient treated with tirofiban for unstable angina and acute coronary syndrome.