J Thorac Cardiovasc Surg 2006;132:442-443
© 2006 The American Association for Thoracic Surgery
Monobloc or separate aortic and mitral homografts?
Christophe Acar, MD
Department of Cardiovascular Surgery, Hôpital Pitié-Salpétrière, 50-52 Bd Vincent Auriol, 75013 Paris, France
To the Editor:
Recently, Obadia and associates
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reported their experience with monobloc aorto-mitral homograft for extensive endocarditis. Since 1994, we have performed combined aortic and mitral valve replacement with homografts in 6 patients (mean age: 31 ± 7 years). However, two separated valves were used for the reasons explained below. The etiology of the valve disease was rheumatic (n = 3), congenital (n = 1), or bacterial endocarditis with abscess of the aorto-mitral junction (n = 2). One patient was undergoing a third reoperation for prosthetic valve dehiscence. As in Obadia's technique,
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the first step of the operation was fixation of the papillary muscles, whose exposure can be very difficult. It was anticipated that a bulky aorto-mitral monobloc, once lowered into position, would somewhat obstruct the access to the papillary muscles. In addition, the use of an aorto-mitral monobloc would necessarily have restricted the panel of available sizes, increasing the risk of mismatch, which has been shown as a factor of mitral homograft dysfunction.
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Thus, it was decided to implant two separate homografts. The aortic and the mitral valve were approached separately through the standard incisions. Part of the papillary muscle sutures were inserted through the aortic orifice. The mitral valve homograft was inserted according to a previously described technique, which invariably included ring annuloplasty.
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This latter technical detail is probably relevant since the use of a prosthetic ring seems to greatly enhance the durability of the mitral homograft.
2
Using the wall of the aortic homograft and a low insertion of the valve so as to exclude the aorto-mitral abscess when present made unnecessary any reconstruction of the left atrial roof. The mean bypass time was 192 ± 11 minutes, which is comparable with the monobloc aorto-mitral technique according to Obadia and suggests that the preservation of an intact aorto-mitral continuity did not spare any significant ischemic time. Among our 6 patients, there was no in-hospital death. One patient died at 47 months of cerebral hemorrhage, and there was one reoperation for recurrence of endocarditis at 69 months. After a mean follow-up of 59 ± 6 months, the remaining 4 patients were asymptomatic and 1 patient had had from a normal pregnancy. In conclusion, although technically challenging, a combined aortic and mitral valve replacement with two separate homografts can also be a valid option in highly selected cases.
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References
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- Obadia JF, Hénaine R, Bergerot C, Ginon I, Nataf P, Chavanis N, et al. Monobloc aorto-mitral homograft or mechanichal valve replacement. a new surgical option for extensive bivalvular endocarditis. J Thorac Cardiovasc Surg 2006;131:243-245.[Free Full Text]
- Ali M, Iung B, Lansac E, Bruneval P, Acar C. Homograft replacement of the mitral valve. eight year results. J Thorac Cardiovasc Surg 2004;128:529-534.[Abstract/Free Full Text]
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Reply to the Editor
- Jean-François Obadia
J. Thorac. Cardiovasc. Surg. 2006 132: 443.
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