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J Thorac Cardiovasc Surg 2003;126:232-238
© 2003 The American Association for Thoracic Surgery

Surgery for congenital heart disease

Human leukocyte antigen-DR and ABO mismatch are associated with accelerated homograft valve failure in children: implications for therapeutic interventions

^a Maritime Heart Centre & Division of Cardiac Surgery,^a Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada;
^b Department of Cardiology,^b IWK Grace Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
^c Division of Cardiac Surgery,^c University of Alberta, Edmonton, Alberta, Canada

Read at the Twenty-eighth Annual Meeting of The Western Thoracic Surgical Association, Big Sky, Mont, June 19-22, 2002.

Received for publication July 10, 2002; accepted for publication December 30, 2002.

^* Address for reprints: Roger J. F. Baskett, MA, MD, Maritime Heart Centre, Room 2269 2nd Floor, 1796 Summer St., Halifax, Nova Scotia B3H 3A7 Canada
RogerBaskett{at}hotmail.com

OBJECTIVE: This study examines the incidence and factors associated with the failure of homograft valves and identifies those factors that are modifiable.

METHODS: From 1990 to 2001, 96 homograft valves were implanted in the right ventricular outflow tract of 83 children (mean age 5.1 ± 5.6 years). Clinical and blinded serial echocardiographic follow-up was performed on all 90 valves in the 77 survivors.

RESULTS: Eighteen homograft valves were replaced as the result of pulmonary insufficiency (3), stenosis (9), or both (6). Freedom from reoperation was 71% at 9 years (95% confidence interval, 58%-84%). Forty-eight valves developed progressive pulmonary insufficiency of at least 2 grades, 26 valves developed transvalvular gradients of 50 mm Hg or greater, and 14 of these valves were also insufficient. The freedom from echocardiographic failure (progressive pulmonary insufficiency 2 grades or 50 mm Hg gradient) was only 27% at 5 years (95% confidence interval, 17%-37%). In a multivariate analysis (Cox regression), use of an aortic homograft (P = .001) and short antibiotic preservation time (P = .04) were associated with reoperation. Younger age (P = .01), ABO mismatch (P = .04), and diagnosis (P = .005) were associated with echocardiographic failure. In the subanalysis of patients with human leukocyte antigen typing, age (P = .002), aortic homograft (P = .04), and human leukocyte antigen-DR mismatch (P = .03) were associated with echocardiographic valve failure.

CONCLUSION: Many homografts rapidly become insufficient and require replacement. In our analysis of both reoperation and echocardiographic failure, several immunologic factors are consistently associated with homograft failure. Matching for human leukocyte antigen-DR, blood group, and avoiding short preservation times (thus minimizing antigenicity) offers the potential to extend the life of these valves.

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