Possible homograft...

[Dana54]

Hello all.....I'm a newbie,this being my first post. I've been lurking for a couple months and am truly grateful and comforted by the information and stories on this site. I'm scheduled for bavr June 5. I'm pretty sure I'm going with the Carpentier-Edwards pericardial bovine magna. My surgeon called the other day and gave me an option (and recommendation) of using a homograft in the event I'll need aortic root repair. (I think my aorta is 3.8 at the moment.) I'm a bit confused with this. A completely different valve. Everything I've seen on the forums indicates dacron repair of an aneurysm. What's with that? I'm pretty sure it's going to be an avr and monitor the aorta thing, but just in case.....Anyone have info on homografts? I thought they weren't used much. Have a short life, etc.. I'm having trouble finding stats and info on homografts. Never liked curveballs. Thanks everyone.

54 years old
bicuspid aortic valve
severe AI (40%) with regurgitation

 

[briansmom]

My son at 16 had to go mechanical so I can't comment on the valve, but I would ask your surgeon why a homograft makes an aortic repair better. I also would want to know why you would not replace the ascending aorta with Dacron while they were in there, otherwise you could be setting yourself up for another surgery down the line when you are older and possibly less healthy.

Have you done a search on this site for homograft? I know there are a few people here who have them.

 

[Ross]

Dana sorry, normally we don't let anything get by without some kind of reply. It's just been a crazy time for the forum. BAV and anerurysms seem to go hand in hand. It's probably best that the aorta be replaced at the same time the valve is.

StretchL has a lot of info on homografts.
http://www.stretchphotography.com/avr/documents/
Another good resource is Ben Smith. Ben will be around, I'm sure, soon to offer his suggestions. If not, simply PM him. I'm sure he'd be happy to talk with you.

I'm thinking your doctor would rather try the homograft in hopes of a lifetime repair vs going the tissue route, which may or may not lead to another surgery down the road. Your relatively young yet, so tissue may not be the best choice. It's hard at your age, because it can go either way. Kind of a coin toss really.

 

[Dana54]

Thanks for the info. Ross....a repair at 3.8? Mmmm, perhaps you're right. I've seen too many get bavr and get root repair a couple years later....Although I wonder how many never need the repair even with some dilation. So many questions.

 

[Mary]

It doesn't make sense to me, Dana, but that's nothing new.
I just put you on the calendar for a June 5 avr. Hate that we have to meet in this manner, but "Hello, and welcome to VR".

 

[ShezaGirlie]

Rose of San Antone..

Rose of San Antone..

Hi there Dana....how did I miss a hometown gal..? Dr. Larry Hamner installed my aortic valve when I was 55 years old...er..young at the Methodist Metropolitan Hospital near downtown.

You've made an excellent choice with the Carpentier-Edwards pericardial bovine magna or a homograph. Sorry that I can't address your aorta issue since I was a plain vanilla aortic valve replacement only.

Again, welcome...!!

 

[Dana54]

Thank you Deanne, and I hope Brian is doing better. Thanks Mary and Sheza....(by the way, I'm a dude....unless I accidently get the wrong operation!) My surgeon is Dr. Edward Sako...University Hospital. I hear he's good.

 

[Ross]

(by the way, I'm a dude....unless I accidently get the wrong operation!) My surgeon is Dr. Edward Sako...University Hospital. I hear he's good.

Well Pairodocs ended up with a small arm attached to his right hip and palmaceae had his head lopped off, so I reckon anything is possible.

 

[tobagotwo]

I agree that if the root is expanded, now is the time to take care of it. However, there are other options for this.

There are mechanical valve combinations with dacron sleeves that generally last a lifetime (most notably from St. Jude), and tissue replacements like the Medtronic Freestyle that encompass the root and the valve that are long-lasting, and don't require anticoagulation therapy.

While they are not unuseful, homografts are an older technology, and seem to do better in the pulmonary position. In most aortic situations, homografts do not last as long as the new tissue valves, and they are considered harder to replace (replaced homografts have been likened to "lead pipe"), so the choice of it strikes me as unusual. Some surgeons believe that it lowers the chance of a repeat case of endocarditis, but I've not seen any science that backs that up with modern valves.

If 54-year-olds were getting aortic homografts that lasted a lifetime, there would be no market for any other tissue or mechanical valves. Instead, use of aortic homografts has dwindled to a very small percentage in adults, as they are difficult to obtain, and don't seem to provide any advantages.

I would certainly be curious about this choice, and find out why he would suggest it. Perhaps he's not had much experience with other products (alarm bells!). If your surgeon tells you that a tissue valve would only last 10 years or so, he is out of date, and that would explain a lot. In either of those cases, you might well want to seek another surgical opinion.

Best wishes,

 

[ShezaGirlie]

Ooooops.....!

Ooooops.....!

Thanks Mary and Sheza....(by the way, I'm a dude....unless I accidently get the wrong operation!) My surgeon is Dr. Edward Sako...University Hospital. I hear he's good.

Sorry about the mistaken gender there HezaDude..

Just a bit of info for you from being on this forum about 10 years now.. Others are so much better versed than I am in selections of valves and I'd sure pay particular attention to what a few others have to say...namely: Tobagotwo, Ross and AlCapshaw.

University Hospital is a great place to be..

 

[flowergal]

Welcome to the forum. In 2000 I had a homograft put in the aortic position,it is intact no leaks and functioning well. I was told it would last around 15-20+ years. Dr Magdi Yacoub put mine in. He has done ALOT!!! They are technically the hardest to put in. I would make sure your doctor has done many if you chose that route.

Good luck

Flowergal

 

[lcwhitney]

PLEASE don't even consider a homograftlasted ! I had one that lasted about 8 weeks before it began to fail and cause me to become symptomatic again. I was told that this grafrt would last forever sine it was used to replace my pulmonic valve, the valve with the lowest pressure of all our heart valves. This valve was replaced less than 2 years after it was originally implanted.It literally came apart in my doctors hands when he attempted to remove the valve.
Lettitia

 

[Dana54]

Hmmm....a third arm might not be so bad....but I don't want my head lopped off. Thanks again all, for the info and welcome. Opposite ends of the spectrum on the info! Either way I guess we roll the dice!

 

[ken]

The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.

The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.

1: J Heart Valve Dis 2001 May;10(3):334-44; discussion 335

The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve
replacements.

O'Brien MF, Harrocks S, Stafford EG, Gardner MA, Pohlner PG, Tesar PJ, Stephens
F.

The Prince Charles Hospital and the St Andrew's Hospital, Brisbane, Queensland,
Australia.

BACKGROUND AND AIM OF THE STUDY: The study aim was to elucidate the advantages and limitations of the homograft aortic valve for aortic valve replacement over
a 29-year period.

METHODS: Between December 1969 and December 1998, 1,022
patients (males 65%; median age 49 years; range: 1-80 years) received either a
subcoronary (n = 635), an intraluminal cylinder (n = 35), or a full root
replacement (n = 352). There was a unique result of a 99.3% complete follow up
at the end of this 29-year experience. Between 1969 and 1975, homografts were
antibiotic-sterilized and 4 degrees C stored (124 grafts); thereafter, all
homografts were cryopreserved under a rigid protocol with only minor variations
over the subsequent 23 years. Concomitant surgery (25%) was primarily coronary
artery bypass grafting (CABG; n = 110) and mitral valve surgery (n = 55). The
most common risk factor was acute (active) endocarditis (n = 92; 9%), and
patients were in NYHA class II (n = 515), III (n = 256), IV (n = 112) or V (n =
7).

RESULTS: The 30-day/hospital mortality was 3% overall, falling to 1.13 +/-
1.0% for the 352 homograft root replacements. Actuarial late survival at 25
years of the total cohort was 19 +/- 7%. Early endocarditis occurred in two of
the 1,022 patient cohort, and freedom from late infection (34 patients)
actuarially at 20 years was 89%. One-third of these patients were medically
cured of their endocarditis. Preservation methods (4 degrees C or
cryopreservation) and implantation techniques displayed no difference in the
overall actuarial 20-year incidence of late survival endocarditis,
thromboembolism or structural degeneration requiring operation. Thromboembolism
occurred in 55 patients (35 permanent, 20 transient) with an actuarial 15-year
freedom in the 861 patients having aortic valve replacement +/- CABG surgery of
92% and in the 105 patients having additional mitral valve surgery of 75% (p =
0.000). Freedom from reoperation from all causes was 50% at 20 years and was
independent of valve preservation. Freedom from reoperation for structural
deterioration was very patient age-dependent. For all cryopreserved valves, at
15 years, the freedom was 47% (0-20-year-old patients at operation), 85% (21-40
years), 81% (41-60 years) and 94% (>60 years%). Root replacement versus
subcoronary implantation reduced the technical causes for reoperation and
re-replacement (p = 0.0098).

CONCLUSION: This largest, longest and most complete
follow up demonstrates the excellent advantages of the homograft aortic valve
for the treatment of acute endocarditis and for use in the 20+ year-old patient.
However, young patients (< or = 20 years) experienced only a 47% freedom from
reoperation from structural degeneration at 10 years such that alternative valve
devices are indicated in this age group. The overall position of the homograft
in relationship to other devices is presented.

PMID: 11380096 [PubMed - indexed for MEDLINE]

 

[ken]

Primary aortic valve replacement with allografts over twenty-five years: valve-relate

Primary aortic valve replacement with allografts over twenty-five years: valve-relate

Primary aortic valve replacement with allografts over twenty-five years: valve-related and procedure-related determinants of outcome

1: J Thorac Cardiovasc Surg 1999 Jan;117(1):77-90; discussion 90-1

Primary aortic valve replacement with allografts over twenty-five years:
valve-related and procedure-related determinants of outcome.

Lund O, Chandrasekaran V, Grocott-Mason R, Elwidaa H, Mazhar R, Khaghani A,
Mitchell A, Ilsley C, Yacoub MH.

Academic Department of Cardiac Surgery, Harefield Hospital, Middlesex, United
Kingdom.

OBJECTIVES:
Allografts offer many advantages over prosthetic valves, but
allograft durability varies considerably. METHODS: From 1969 through 1993, 618
patients aged 15 to 84 years underwent their first aortic valve replacement with
an aortic allograft. Concomitant surgery included aortic root tailoring (n =
58), replacement or tailoring of the ascending aorta (n = 56), and coronary
artery bypass grafting (n = 87). Allograft implantation was done by means of a
%2"freehand" subcoronary technique (n = 551) or total root replacement (n = 67).
The allografts were antibiotic sterilized (n = 479), cryopreserved (n = 12), or
viable (unprocessed, harvested from brain-dead multiorgan donors or heart
transplant recipients, n = 127). Maximum follow-up was 27.1 years.

RESULTS
Thirty-day mortality was 5.0%, and crude survival was 67% and 35% at 10 and 20
years. Ten- and 20-year rates of freedom from complications were as follows:
endocarditis, 93% and 89%; primary tissue failure, 62% and 18%; and redo aortic
valve replacement, 81% and 35%. Multivariable Cox analyses identified several
valve- and procedure-related determinants: rising allograft donor age and
antibiotic-sterilized allograft for mortality; donor more than 10 years older
than patient for endocarditis; rising donor age minus patient age, rising
implantation time (from harvest to aortic valve replacement), and donor age more
than 65 years for tissue failure; and rising donor age minus patient age, young
patient age, rising implantation time, and subcoronary implantation preceded by
aortic root tailoring for redo aortic valve replacement. Estimated 10- and
20-year rates of freedom from tissue failure for a 70-year-old patient with a
viable valve from a 30-year-old donor and no other risk factors were 91% and
64%; the figures were 71% and 20% if the donor age was 65 years. The rates of
freedom from tissue failure for a 30-year-old patient with a 30-year-old donor
were 82% and 39%; the figures were 49% and 3% with a 65-year-old donor.
Beneficial influences of a viable valve were largely covered by short harvest
time (no delay for allografts from brain dead organ donors or heart transplant
recipients) and short implantation time.

CONCLUSIONS:
Primary allograft aortic
valve replacement can give acceptable results for up to 25 years. The late
results can be improved by the use of a viable allograft, by matching patient
and donor age, and by more liberal use of free root replacement with
re-implantation of the coronary arteries rather than tailoring the root to
accommodate a subcoronary implantation.

PMID: 9869760 [PubMed - indexed for MEDLINE]

 

[Dana54]

Thanks Ken. It's a bit hazy, in that the older non cryo homografts are included in their studies. I also wonder if any calcification slowing process is applied to homografts in the past few years. I kinda doubt it. My instincts tell me the dacron repair and staying with the bovine valve gives me better odds of longer use....Or...does a slightly higher risk of endocarditis negate that? .... I notice that, although I don't see many of them, the Cleveland clinic uses aortic homografts. (Probably for endo cases.) Yet another coin flip. Good grief.

 

[TFBruce]

Hi there-
I am not sure if you are locked in with your choice of surgeons, but if not, would recommend you speak to Dr. Oswalt in Austin. Cardiothorasic and Vascular Surgeons, across the street from the Heart Hospital, on Lamar.
I would be happy to give you his number if you are interested. He is one of the best in the US.

 

[Dana54]

Thanks Bruce, I'm basically locked in (surgery date June 10), but it wouldn't hurt to get another opinion. I can always change my mind. My surgeon makes sense in that he says it's a tough second avr replacement years down the road, if I have a dacron tube. Easier with the homograft because it's almost like doing avr to a native valve. Still, I notice there's alot of dacron patches being done with the bovine pericadial....Cleveland Clinic, etc...so yeah....can you send me your doc's number? Still, at 3.7 or .8, he may not do the root. Says he might just tighten it up some. Thanks, Dana [email protected]

 

[zipper2]

Sorry no information to your questions,lots of great answers though.
Just wanna say hi and welcome,glad your here sorry for reason.
All the best for June and ask away usually someone does get your
questions answered with their knowledge or their experiences.

zipper2 (DEB)