Ross-Homograft

[Granbonny]

Can someone explain to me the difference in these 2 valves?Are they the same?Lisa, just noticed you have a homograft...The reason I ask.. A home builder in my gated community ( Only builds the $500,000 homes here) had a Homograft 6 months before me. Was talking to him 2 years ago and he said, he would never have to have his replaced and only see a PCP..No Cardiologist. Have not seen him around lately..Would love to know how he is doing..I think I'll ask around and see if anyone knows...He is my age. 64..Bonnie

 

[Shine_on_Syd]

The Ross is a procedure to replace the aortic valve with the pulmonic valve.
An aortic homograft is from a human donor as opposed to animal tissue valves such as bovine or porcine. An aortic homograft is harvested from a human heart.

Quote from: http://ps4ross.com/ross/autograft.html
The Autograft

Substituting the patient's pulmonary valve for the aortic valve is the only replacement that is truly alive and potentially able to last a normal lifetime without blood thinners or further surgery. This technique is called a pulmonary autograft.

The pulmonary valve has the same embryological origin although its structure under the microscope is slightly different from the aortic valve. The pulmonary valve normally faces much lower pressures than the aortic valve, but under test conditions, the pulmonary valve has proven reliable at aortic pressures. The pulmonary autograft has been shown to grow with the rest of the body in young children. No other valve substitute can do this.

Rarely, a pulmonary valve may have only two leaflets (bicuspid) or be intrinsically unusable due to its own disease or previous surgery. The biggest drawback is that the operation is longer and demanding of a surgeon's skill and concentration, with a higher risk of bleeding. The other intrinsically limiting factor becomes the replacement valve in the pulmonary position. Here, the homograft has proven itself to be a durable substitute, significantly better than in the aortic position, regardless of how it is preserved.

 

[Ross]

He's being foolish if he's not followed by a Cardiologist!

 

[Granbonny]

That's why I haven't seen him for 2 years. LOL. He built the home across from me and the one next door to me.. They were finished 2 years ago..LOL. Bonnie

 

[tobagotwo]

Homografts

Homografts

If he didn't have a Ross procedure, he may still have had a homograft. It's just a tissue valve taken from a human cadaver, rather than a pig's or cow's.

It is treated to reduce rejection, although homografts are the only valves of any type that I have ever read of having immunological issues. I believe Surfsparky may have had a partial rejection-reaction issue in the pulmonary homograft from the Ross procedure, if I recollect properly.

The average valve life for an aortic mount homograft seems to be around 20 years, doing better in older recipients than younger ones. When they begin to "expire," homografts tend to harden up, perhaps due to rejection processes.

Originally, it was believed that your own tissue would grow over the cadaver's valve, and it would gradually become "your own" valve. However, that theory has not panned out in practice. The valve still has a long life and is an exact replacement, which no other type can claim.

Best wishes,

 

[Lisa]

Homograft

Homograft

Hi, Bonnie. I'm hoping to make up your way later in year. I want to try that hike to Anna-Ruby Falls now that I've had the valve replacement! I bet I won't be short of breath this time!

Anyway, Bob & Syd have nicely explained the difference, so I won't go into that.

I just had my 3 month echo done on Tuesday of this week and the echocardiologist said that if she didn't know I had just had the AVR, it would be hard to tell it from a 'native' valve. She said it sounds like a 'normal' heart in every way. The only difference in the pictures is that you can where they stitched inside. The stitched areas show up a lighter color on the echo. That's all she could tell me.

I have my follow-up with my cardiologist today. He will hopefully tell me how this valve is doing. I'm wondering about my leaky mitral valve. It is supposed to clear up on it's own, after the AVR.

Bob, where did you find information on rejection? I did a lot of research and asked a lot of questions and basically, the chance of rejection is minimal. You aren't even given ANY type of anti-rejection medication while in the hospital.

I thank God every day that someone cared enough to leave their organs behind. I'm an organ donor (perhaps this belongs in another thread) and hope that other valvers are as well.

 

[tobagotwo]

If I understand from what I've seen, it is not usually a quick process, like a liver rejection, but rather a slow hardening of the tissue in the homograft, attributed to the actions of the autoimmune system. This is as opposed to the calcification that usually detriments a bovine or porcine-based valve. I should have been more careful with the term, lest it raise unnecessary concern.

I was hoping Surfsparky might chime in - if I have the right person, to tell us more from recent direct experience.

Best wishes,

 

[Mary]

Bob,
I checked this morning, and you were correct. It is Surfsparky. Chris had the Ross and is now having trouble with the pulmonary valve. I don't know the time difference between here and there, but maybe they'll post later in the day.
Mary

 

[Lisa]

Calcification vs. Rejection

Calcification vs. Rejection

Thanks, Bob. Just a clarification on my part: The homograft (according to my surgeon and cardiologist) will eventually need replacing due to calcification, not rejection. That's why I asked where you got your information. It will make interesting reading for me. I'm not alarmed. Thanks for the info.

Also, not all recipients of a homograft have the aortic root replaced. I didn't. All that I had replaced was the aortic valve. Perhaps this is new technology. It would be interesting to know how many others had just the valve replaced.

 

[Kenny F]

My valve was a homograft. The valve and the root up to the branches was used. I am on no meds. Life expectancy of the valve is stated at 20 years because that is all the data available. Many docs believe in the right cases it could be a permanent fix. Mine was sized like the original (what was left of it) and "sounds like a new heart" to my cardio.

I only see my cardio annually.

 

[Granbonny]

Hi Lisa

Hi Lisa

Be sure and let me know when you come up to our beautiful N.E. Georgia Mountains. I only live 15 minutes from Anna Ruby Falls. Now, the tourist part is very easy walk to Falls. but they have added another 5 miles around back to Parking Lot. Another one you may want to do is Dukes Creek Falls. a good hike down to Falls. Close by.............Dukes Creek is where Gold was discovered in 1821...man claimed to have found an egg sized gold nugget down on the creek.............O.K....I found the whereabouts of my friend who had the Homagraph...Seems like he turned the business over to a son. Friend said she heard he was having health problems. I will try to find out more...Bonnie

 

[tobagotwo]

LIsa,

This isn't working for me.

I'm thinking, "no problem." I pulled up the three links I saved from my 2000/2001 research on homografts, which were to reinform me if I was lost again in the decision process. All three came up couldn't-finds. I did pull two others that didn't discuss the end-of-valve-life side, and which did say that homografts were done root intact and partial aorta.

OK, so get it on the web. I found more sites which only mention the one type, but then two sites that discuss three different types of homografts, including the rootless variety. Ergo, these have newer data, and I have misinformed.

I found two items that talk about homograft rejection. One is a thesis (derivative crap: http://www.timirwin.com/Projects/Current Status of Aortic Valve%), another is a treatment of homograft rejection studies so dense that I'm not sure what their actual conclusion was, as I have trouble staying interested. It established that there was rejection going on, but the grafts that had early rejection fared better long-term than the ones that did not (meaning it was not fatal to the graft). The distinctions came between fresh- and long-term-frozen homograft valves. A mention was also made regarding the Cryolife dry-freeze process (begun in 1985), which removes the HLA class(1) and class(2) antigens that had encouraged rejection in the other valves. Nasty reading. http://www.bhj.org/journal/2002_4404_oct/org_res_632.htm

As such, it is only proper to remove the statement regarding rejection. And the statement about the root always being involved, which is no longer the case. I apologize for not rechecking my data before opening my big yap. I am completely embarrassed that I cannot source this for you, Lisa.

I am also annoyed, because the topic fascinated me three years ago, and now I can't even back myself up with it. I don't know if it is because the cryofrozen valves no longer have the problem, rendering it moot, or because the articles were based on a flawed study and withdrawn. I will do more homework on this. It's a big web. I should be able to refind at least one of those articles just to look at.

Mortified,

 

[tobagotwo]

Lisa,

Rejection search is going better, now. I wasn't crazy after all. My Frantic Search skills were rusty. No, Ross, I didn't Google yet.

Note: The root requirement for homografts is definitely no longer the case. I am not even researching that one further. Thank you for updating that. I have modified my earlier post for that issue.

re: rejection. I did not re-find the original posts. However, here are a few others to get going with. If I get obsessive, more will come...

Testing done to determine the causes of homograft degeneration:
http://www2.us.elsevierhealth.com/scripts/om.dll/serve?article=a80549&nav=abs

"Homografts in children failed in as little as three months as a result of cellular rejection." http://www.shvd.org/file/6487.htm

"Homograft replacement occurred in only 3 patients...The other 2 patients had pulmonary stenosis. We believe the cause of stenosis was likely related to a rejection phenomenon." http://www.ctvstexas.com/a_highlights_ross.html

And I found SurfSparky's thread: http://www.valvereplacement.com/forums/showthread.php?p=80035#post80035

Less mortified,

 

[Lisa]

Thanks, Bob.

Thanks, Bob.

Wow! This is going to be interesting reading. Don't get obsessive (for me anyway) unless it's for your own edification.

I read SurfSparky's thread. I don't know anything about pulmonary valves. That makes one more topic I have to explore.

Thanks for the perseverance. I recognize the trait. I'm like a dog with a bone when something sparks my interest, so I can appreciate your determination to find out more.

Lisa

 

[tobagotwo]

The pulmonary is the valve used to replace the aortic valve in a Ross procedure. Then the empty pulmonary position is replaced, usually with a homograft.

In the lower-pressure pulmonary position, any substitute valve should last longer than in the aortic position. This generally makes the homograft a standout choice for it, with its completely natural structure and usual longevity.

It's the same valve as the aortic, located right next to it, but under less pressure. Apart from the stress of that extra pressure, they should reasonably have the same responses, including any immunological activity.

When I was first reading about it, they made a much bigger deal about possible rejection reactions, which was partly responsible for my not deciding on that direction. However, I still do not recall reading of them giving anyone anti-rejection medications for it, which has to mean that the risk wasn't that high. I do remember reading descriptions about the tissue of the valve becoming very stiff and hard over time as a result. There is also calcification that occurs, as I believe you spoke of, but this hardening of the tissue was referred to separately.

In trying to decipher that first study (yawn), there were comments regarding differences in the variety of preparations, and in the types and lengths of freezing of the valves, as well as "hot" transplants.

One point they made was that there were difficulties with "fresh" valves, and different immunological activity between just-frozen, and even days-old-frozen valves. The appearance is that for commercial availability, Cryolife pretty much stole the market with a freeze-drying technique in 1985 that eventually allowed a salable inventory of valves to be built up.

Some of the documentation that was available to me at that time may well have been taken from the outcomes of numerous, dissimilarly-prepared implanted homografts from before 1990. That's the bulk of the data that would have been available.

As the variables have reduced along with the number of preparation techniques, the rejection issue may be slowing down and thus, less interesting to Those Who Do Studies (you know: "Them," or the generic form of the term "scientists," which includes many people who are indeed not).

Regardless, strong, upfront responses, like SurfSparky's would not be common at all, and if they don't happen right away, would not likely happen in any sudden fashion later.

I'd still like to run across one of my originally linked treatises, as they were much more lively reading. Maybe the stuff got old and just got rotated off.

Regardless, you're not in any danger for a couple of decades at least. I know you realize it, but I hope that much is also clear to other readers. The information certainly wasn't aimed to strike fear in the hearts of anyone.

Best wishes,

 

[surfsparky]

Surfsparky finally logging on!

Surfsparky finally logging on!

Hi Lisa, Bob, Mary etc,
Chris here...finally! Yep, I'm the one that is currently having problems with my donor valve in the pulmonary position. From my research, stenosis occurs in approx 10% of cases, but it is quite rare for it to worsen to the point of resurgery. Unfortunately, my stenosis is at a point where it is at the highest level my surgeon has ever seen (which he's not happy about as he has an untarnished record!). He says that the stenosis is not due to calcification, but rather to an auto immune response. Because it is uncommon, they are not sure of the reasons for this "rejection phenomenon". It could be from the preservation techniques, but another area my surgeon is exploring is whether it could be due to the donor valve coming from a different blood type to my own. It's just a theory, but one my surgeon is having his med students research. The preservation techniques should supposedly strip the valve of it's "origin", but who knows? In Australia, the human donor valves are not blood matched from the cadaver to recipient, purely for availability reasons. Don't worry Lisa, this is really rare, and it sounds like your homograft is going great if when they listen to it, it sounds like a regular heart. Can't wish for a better outcome than that!
Regards,
Chris

 

[Mary]

Chris,
I'm sure glad you posted. I intend to have the Ross procedure sometime this year. The surgeon says it's a go. Of course, I have worried about the pulmonary valve replacement and the likelihood of reoperation. Perhaps someone knows if they blood match the valves in the United States. Chris, would you mind if I sent a copy of your post to my surgeon so he can address the question?
Thanks,
Mary

 

[surfsparky]

Sure Mary!

Sure Mary!

Hi Mary,
Feel free to email my post to your surgeon, I'd be interested in his response too. Another thing I'll mention too is that, my cardio mentioned something interesting in that, with all the scars on my body (especially the chest scar), my body has tended to "over-scar" them. Even scars from chicken pox, small cuts etc, the scars have become quite thick, rather than reducing in size & fading over time. Maybe I've always had the type of immune system that over-compensates when things are not normal. There maybe nothing in this observation, but it was an interesting thought. I'm going to look up the links that Bob posted (thanks Bob), and see if anything rings true for my case.
Regards,
Chris

 

[bvdr]

Surfsparky,

Maybe your experience with scarring externally is a reflection on how you scar internally as well. One of the questions I was asked before my heart surgery was if I had a history of forming keloids on scars. At the time I thought it might make a difference on what type of incision and closure they would make. On reflecting on your comment, I am now wondering if perhaps there was more behind the question.

Mary, I hope all goes well for you and that you end up with exactly the right operation for you. The best to you.

 

[surfsparky]

I think you're right Betty. I agree that there may be something behind the question when they asked whether you have a history of keloid scarring. I do have keloid scarring, but this wasn't checked for or looked at until after my surgery. It would be interesting to find out whether those who have problems with scarring over their new valves (or the "rejection phenomenon" as some studies put it), also have keloid scarring.
Hmmmm, interesting...
Thanks for your input,