Valve question - just curiosity

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Adrienne

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Joined
Sep 3, 2006
Messages
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Location
Montreal, Canada
I have a question which does not affect me since I had a mitral valve repair, but having learned all kinds of things about valve replacements, the things I learned brought a question to my mind. I see that with the Ross Procedure, they use your own pulmonary valve and put it in the aortic position, then they replace the pulmonary valve with a homograft. At first, I didn?t understand why this round-a-bout way of doing things, but now I do. However, my question has to do with the fact that they use a homograft at all. If they are able to use a valve from a human cadaver for the Ross Procedure, why are they not able to use one for just normal replacements of any valve? Is it simply that there are not enough of them? Also, when they use a homograft, is there less chance of calcification? If so, that really makes my first question an important one!
 
And, Adrienne, while someone answers those questions, I wonder if a tissue valve can safely be used in the pulmonary position, rather than a homograft?
 
Adrienne said:
If they are able to use a valve from a human cadaver for the Ross Procedure, why are they not able to use one for just normal replacements of any valve? Is it simply that there are not enough of them? Also, when they use a homograft, is there less chance of calcification? If so, that really makes my first question an important one!

Hi, Adrienne. I think I have some insight for you.

A human donor valve, also known as an allograft, can be used in the aortic position. The problem with having one there is that it doesn't last very long on that higher pressure side of the heart. I'm pretty sure they don't last as long in the aortic position as a porcine or bovine valve. There are also fewer of the allografts around.

In the pulmonic position, the allograft's track record is much better, probably due to the lower pressures there. Also, if/as it eventually fails, it's *much* less of an issue than if it were in the aortic position. Finally, the replacement on the pulmonic side is a much more simple procedure, both for the patient and the surgeon.

Finally, in the pulmonic side, a pulmonic donor valve lasts longer than an aortic donor valve, which is interesting...

Hope all's well!
 
The short answer to both is yes.

Homografts (AKA allografts - aortic valves from cadavers) have been in use for many years. They last fairly well - originally longer than xenografts (AKA heterografts - bovine or porcine valves) lasted, especially in younger patients. They also didn't require anticoagulation treatment (warfarin, Coumadin).

However, there is a low level of immune system rejection involved in the use of a homograft, especially in the aortic position. After a dozen years or so, they have been described as being "like a lead pipe," rock hard and heavy. The current xenografts outlast them, which is why they are not often used for aortic replacements anymore.

However, homografts are more often used in the pulmonary position for the Ross procedure. And they often do cause a crisis at some point with rejection (usually in the form of the valve narrowing significantly), but they generally get past it and continue to function. For some reason, in the lower-pressure environment, they last much longer, sometimes for the recipient's lifetime. They are sometimes replaced with a xenograft, if replacement is necessary. Some surgeons do use xenografts in primary Ross surgeries, but it's not widespread.

My guess is that the xenograft would calcifiy more rapidly, as the blood is moving with less pressure, allowing chemical bonds (and thus deposits) to form more easily, a problem which shortens the life of tissue valves in the mitral position.

What effect the anticalcification treatments found on the newer valves might have on their use in Ross Procedures is uncertain at this time. It will be more than a decade from now before real data starts developing as to the treatments' effectiveness in more difficult conditions, such as chemically active young patients.

Best wishes,
 
Thanks for asking that question Adrienne. I had wondered that too. And thanks Stretch and Bob for your answers.
 

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