Aortic allograft valve reoperation: surgical challenges and patient risks

BACKGROUND: Aortic valve allograft reoperation is a challenge for the surgeon and a risk to the patient. We examined our experience to identify these challenges and risks. METHODS: From April 1987 to January 2006, 130 patients underwent first-time allograft-related reoperations. Prior implant was subcoronary 32 (25%), inclusion-root 28 (22%), and root 70 (53%). Reoperative indications were technical failure 11 (8.4%), endocarditis 31 (24%), and structural valve deterioration 88 (68%). Reoperative technique was allograft repair 7 (5.4%), simple valve replacement 80 (62%), and root replacement 43 (33%). Median follow-up was 3.1 years. RESULTS: Surgical challenges: 10 adverse intraoperative events occurred (7.7%), 3 allograft specific, with rescue from all. Reoperative procedure was highly dependent on original implantation technique (31 of 43 root replacements after previous roots) and reoperative indication (24 of 43 root replacements for endocarditis). Implanted valve prostheses were small for patient size, less so in intact native roots (previous subcoronary or inclusion root) than retained allografts (Z-value, -1.1 versus -1.6; p = 0.08), but allograft root re-replacement allowed normal-sized valves. Patient risks: Relevant postoperative morbidities included reoperation for bleeding 7 (5.4%), new pacemaker 6 (5.2%), stroke 1 (0.8%), and no myocardial infarction. Hospital mortality was 3.8% (5 of 130), 6.5% (2 of 31) for endocarditis. Late patient survival was substantially worse for endocarditis than for structural valve deterioration (60% versus 90% at 5 years, p = 0.0006). Five-year freedom from further reoperation was 94%. CONCLUSIONS: Surgical challenges, even with endocarditis, can be surmounted and patient risks minimized by thoughtful preparation and appropriate reoperative procedure. An intact native root maximizes surgical options.