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J Thorac Cardiovasc Surg 1994;107:1161-1162
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Accelerated degeneration of aortic homograft in an infant

Department of Cardiovascular Diseases
King Faisal Specialist Hospital and Research Center
Riyadh 11211, Saudi Arabia

To the Editor:

Aortic valve homografts have been used in the repair of complex congenital cardiac anomalies ¹ and are preferred over bioprostheses and mechanical valves with their well-known long-term limitations ² We report the case of an infant undergoing implantation of a cryopreserved aortic homograft for truncal valve regurgitation. Reoperation was necessary because of calcification and severe regurgitation of the homograft, detected 3 months after implantation. We present this case to warn of the potential early degeneration of aortic homografts in infants.

A 1-month-old female child weighing 2.8 kg, with a diagnosis of type III truncus arteriosus, underwent a corrective operation. The truncus was overriding a large ventricular septal defect. The right and left pulmonary arteries were arising on either side of the ascending aorta. The truncal valve was quadricuspid with mild regurgitation and a peak gradient of 30 mm Hg. The ventricular septal defect was repaired so that flow was directed from the left ventricle to the aorta. The pulmonary arteries were detached from the truncus with a cylinder of aortic tissue and anastomosed directly to the right ventricle with pericardial augmentation. There was no valve in the right ventricular–pulmonary arterial connection. She was discharged with mild-to-moderate regurgitation of the truncal valve. The child was catheterized after 2 months for worsening dyspnea and was found to have severe truncal valve regurgitation. At a second operation the truncal valve was replaced with a 19 mm cryopreserved aortic homograft root (Royal Brompton National Heart and Lung Hospital, London, United Kingdom) with coronary transfer. She was discharged home with trivial central regurgitation of the homograft valve. A chest roentgenogram at 3 months' follow-up showed severe calcification of the homograft (Fig. 1). Echocardiography showed severe regurgitation of the homograft with calcification of the walls. Five months after implantation of the homograft she underwent a third operation when the homograft was found to be severely regurgitant as a result of retraction of the leaflets and calcification of the cusps and aortic wall. The homograft was replaced with a 16 mm CarboMedics mechanical prosthesis (CarboMedics, Inc., Austin, Tex.), placed inside the root with pericardial augmentation. The chest was left open after the operation because of poor hemodynamic status. Over the next 3 days she had repeated episodes of pulmonary hypertension of which she finally died.

View larger version (115K): [in this window] [in a new window]   Fig. 1. Chest x-ray lateral view showing calcification of the homograft root 3 months after implantation.

The advantage of homograft implantation in infants has to be tempered with the fact that early calcification, degeneration, and regurgitation of the homograft occurs, necessitating reoperation. ¹ Clarke and associates ⁵ have suggested adding immunosuppressive therapy in an effort to alleviate this early allograft degeneration, on the basis that this process is immune mediated. The long-term outcome of such a policy is still awaited. Lately, resurgence of the pulmonary autograft procedure has offered good early and medium-term results in this difficult subset of patients. ⁶

We report this case of an infant undergoing cryopreserved aortic homograft implantation in whom calcific degeneration and regurgitation developed as early as 3 months after implantation to caution of the possible early failure of aortic homograft implants in infants.

References

1. Clarke DR. Extended aortic root replacement with cryopreserved allografts: Do they hold up? Ann Thorac Surg 1991;52:669-75.
   
2. Matsuki O, Robles A, Gibbs S, Bodnar E, Ross DN. Long-term performance of 555 aortic homografts in the aortic position. Ann Thorac Surg 1988;46:187-91.
   
3. William DB, Danielson GK, McGoon DC, Puga FJ, Mair DD, Edwards WD. Porcine heterograft valve replacement in children. J THORAC CARDIOVASC SURG 1982;84:446-50.
   
4. Milano A, Voerhe PR, Verinant FB, et al. Late results after left-sided cardiac valve replacement in children. J THORAC CARDIOVASC SURG 1986;92:218-25.
   
5. Clarke DR, Campbell DN, Hayward AR, Bishop DA. Degeneration of aortic valve allografts in young recipients. J THORAC CARDIOVASC SURG 1993;105:934-42.
   
6. Gerosa G, McKay R, Davies J, Ross DN. Comparison of the aortic homograft and the pulmonary autograft for aortic valve or root replacement in children. J THORAC CARDIOVASC SURG 1991;102:51-61.
   

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ganga Prabhakar Zohair Al-Halees Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gallo, R. Articles by Duran, C. M. G. Search for Related Content PubMed Articles by Gallo, R. Articles by Duran, C. M. G.