What do we know (first hand) about homografts?

[surfsparky]

Hi Karen,
Welcome to this great site!
I too, have had the Ross Procedure done 2 years ago (at age 31). I am very happy about it, and would make the same choice again. A close friend of mine had the Ross Procedure too and is doing well too. If you would like to know more about the procedure, feel free to ask. I can recommend a brilliant surgeon, but unfortunatley he's a little far from you - Australia!
All the best in your research...there's no one perfect choice, but I'm sure you'll make the best choice for you.

 

[neal1234]

I was born with a bicuspid aortic valve having OHS at the age of 33, my first choice was the Ross Procedure unfortunately my valves were not the same size to undertake the swop, I therefore opted for a homograft in the aortic position. Operation was a success and I have definitely noticed the difference. According to the surgeon who is the head of cardiology at a leading teaching hospital in London he reckons it could last 20 years, only time will tell if this prediction is correct.
For me the experience of OHS was no where near as bad as I thought it was going to be.
All the best whatever option you choose.

 

[Karen7]

UK is the place

UK is the place

I was born with a bicuspid aortic valve having OHS at the age of 33, my first choice was the Ross Procedure unfortunately my valves were not the same size to undertake the swop, I therefore opted for a homograft in the aortic position. Operation was a success and I have definitely noticed the difference. According to the surgeon who is the head of cardiology at a leading teaching hospital in London he reckons it could last 20 years, only time will tell if this prediction is correct.
For me the experience of OHS was no where near as bad as I thought it was going to be.
All the best whatever option you choose.

Hi Neal,

Thanks, it's great to hear that you're doing well and happy with your homograft. I hope you get the 20 years . It seems like for human tissue valves, the UK is more experienced and successful than we are here in the states. I hope we catch up.

Karen

 

[Karen7]

brilliant surgeon

brilliant surgeon

Hi Karen,
Welcome to this great site!
I too, have had the Ross Procedure done 2 years ago (at age 31). I am very happy about it, and would make the same choice again. A close friend of mine had the Ross Procedure too and is doing well too. If you would like to know more about the procedure, feel free to ask. I can recommend a brilliant surgeon, but unfortunatley he's a little far from you - Australia!
All the best in your research...there's no one perfect choice, but I'm sure you'll make the best choice for you.

Hi Surfsparky,

We looked into "out-of-network" benefits (Australia is WAY OUT) and we decided that we would just do the best we can in Maryland Thanks for sharing your experience with the Ross Procedure. They do a lot of those here and I need to do more research. I hope to find a brilliant surgeon here too.

Karen

 

[Mary]

Hi Surfsparky,

We looked into "out-of-network" benefits (Australia is WAY OUT) and we decided that we would just do the best we can in Maryland Thanks for sharing your experience with the Ross Procedure. They do a lot of those here and I need to do more research. I hope to find a brilliant surgeon here too.

Karen

Karen,
Dr. Paul Stelzer is pretty darn brilliant. He concentrates on adult Ross procedures and has more than 300 under his belt. He works out of Beth Israel Hospital in New York City. Several members have had him as their surgeon.

 

[dcpickle]

I happen to be one of those whose Ross Procedure was done by Dr. Stelzer, and yes I recommend him highly, but I want to make a comment about "in-network" surgeons. Dr. Stelzer was out-of-network for me, so I had to pay a small amount more. But more importantly, the hospital was IN-NETWORK. That's where the big money was!

My advice is to find the best surgeon you can and only worry about whether the hospital is in-network. Perhaps the anesthesiologist, too. And travel if you have to. My wife and I spent a week in NYC without kids in an apartment after my surgery, and it was actually a wonderful time we will remember fondly.

David

 

[Karen7]

I happen to be one of those whose Ross Procedure was done by Dr. Stelzer, and yes I recommend him highly, but I want to make a comment about "in-network" surgeons. Dr. Stelzer was out-of-network for me, so I had to pay a small amount more. But more importantly, the hospital was IN-NETWORK. That's where the big money was!

David

Hi David -- Thank you, I didn't know that. It never occurred to me that some out-of-state hospitals are in-network. When we asked our benefits manager, he said our "portion" of the total out-of-network benefits was likely to be $30K or more. I will definitely look into that. Recovering in peace the way you did sounds ideal!


Karen

 

[catwoman]

Karen:

I became concerned about the anesthesiologist's bill a week pre-op. An RN had called from my insurance carrier to tell me all about my upcoming valve surgery. (FYI: She was obviously reading from a script. I already knew more than she did on valve surgery!) She said my doctors & hospital were in network, which I knew, but said it was possible that the anesthesiologist might not be. I called the hospital & surgeon's office, asked how I could find out which anesthesiologist would be used. I was told no one knew at that point, or something like that.
My RN sister told me how much anesthesiologists have billed for various procedures she had had in the past couple of years (hip joint replacement being the most expensive) and I began hyperventillating.
She told me to get names of all anesthesiologists on staff at Baylor & see how many are in network with United Health Care. Nearly all were.

I was extremely fortunate. I only had to pay $100 out of pocket for my surgery, under policy terms in 2003. This year it would have cost much more.

Insurance rates continue to increase and employers are shifting more of the burden onto employees. Another reason to shoot for only one surgery: Not only will you be older and probably take longer to recuperate on down the road, but you'll pay more for a re-op.

 

[Karen7]

Karen:

My RN sister told me how much anesthesiologists have billed for various procedures she had had in the past couple of years (hip joint replacement being the most expensive) and I began hyperventillating.

Another reason to shoot for only one surgery: Not only will you be older and probably take longer to recuperate on down the road, but you'll pay more for a re-op.

Hi Marsha,

Thanks for the tip! Don't you love having medical people in the family? They can really save us some grief. Hyperventilating, huh? That's how I respond to the astounding medical fees associated with heart surgery too Our insurance has a HUGE gap between in-network benefits and out-of-network. They are obviously structured to keep people very local.

Thanks again,
Karen

 

[Mary]

My brother-in-law is a general surgeon in San Francisco. Recently my husband and I asked him to help us wade through the contradictory information out there about bicuspid aortic valve, aneurysm, women & heart disease, etc.
He is recommending that I go to Johns Hopkins to see a specialist in homograft valves because his reading has persuaded him it's important for me to look into. I'm still in my childbearing years and I am not likely to be compliant in a -thinning regiment -- at this point. The surgeon that I have already seen (Washington Hospital Center) said he would use a Medtronics Freestyle stentless porcine valve and that was looking pretty good to us.
Who has a homograft? Any regrets? Anybody know the surgeons at Hopkins first hand?
Thanks for your input,
Karen

Karen,
Now that you have had some responses to your original question, have you passed the information on to your brother-in-law? Monetary questions can be answered after you've reached the decision on who is doing the surgery and where.
Mary

 

[Karen7]

Not yet!

Not yet!

Karen,
Now that you have had some responses to your original question, have you passed the information on to your brother-in-law? Monetary questions can be answered after you've reached the decision on who is doing the surgery and where.
Mary

Oh dear, Mary, thank you for asking but I don't think my brother-in-law would think I had been entirely thorough in my research which so far consists of going online and polling heart valve recipients (mostly who don't have homografts.) But this thread has been TREMENDOUSLY helpful in helping me to identify the issues that I need to address.

I will be consulting with Dr. John Conte at JH on August 22: My questions are: Are the advantages of a homograft in practice what they are in theory? How long do they last compared with a stentless porcine valve? Are they more resistant to infection? How do they size them ahead of time? What will they do if they don't have one that "fits" me? When homografts go bad, what are the reasons? How often does this happen? If my coronary arteries are in great shape (and they are) does it make sense to get an AVR of a kind that replaces them as a homograft does? Are they likely to calcify so much they are difficult to repair or replace? What is the exit strategy in this case? Is the Ross Procedure a good option for someone like me?

What do you think, Mary? Did I miss anything?

Karen

 

[Karlynn]

Oh dear, Mary, thank you for asking but I don't think my brother-in-law would think I had been entirely thorough in my research which so far consists of going online and polling heart valve recipients (mostly who don't have homografts.)

Hmmm, it might be that this means you have an answer to your question. We have a lot of tissue valvers here. (of which I am not) But the fact that not many have weighed in on homographs may be an answer to your question.

 

[Karen7]

Yup

Yup

Hmmm, it might be that this means you have an answer to your question. We have a lot of tissue valvers here. (of which I am not) But the fact that not many have weighed in on homographs may be an answer to your question.

You know what? I was just thinking what you posted!

Thanks Karlynn,
Karen

 

[Lynlw]

I was thinkingthat too. My son has tissue but he has bovine, Lyn www.caringbridge.org/nj/justinw

 

[Mary]

Actually Karen,
I was just trying to get the thread back on track. It looked like we were starting to wander off, so I wanted to repost your original question.

 

[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.

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

--------------------------------------------------------------------------------

http://www.ncbi.nlm.nih.gov/entrez/...6&dopt=Abstract

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

Primary aortic valve replacement with allografts over twenty-five years

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

--------------------------------------------------------------------------------

http://www.ncbi.nlm.nih.gov/entrez/...0&dopt=Abstract

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]

 

[Karen7]

subcoronary implantation

subcoronary implantation

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

--------------------------------------------------------------------------------

http://www.ncbi.nlm.nih.gov/entrez/...0&dopt=Abstract

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.

...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]

Ken, I can't thank you enough for finding these. I know that my brother-in-law has read positive things in his medical journals about homografts and I have been unable to discover any of these studies myself -- so this is a great benefit to my research.

Can anyone explain the meaning of "re-implanation of the coronary arteries" versus "subcoronary implantation?"

Karen

 

[Karen7]

Right on, Alan

Right on, Alan

Karen,

My cardiologist and cardiac surgeon advised me against homograft.

· Homograft hardens over time and turns into a ?lead pipe? and can be quite difficult to replace. This I think is the most important issue to consider ? exit strategy.

Well, Alan,

The surgeon I saw at Hopkins agreed with you. He said the current human tissue valve is an excellent choice for a 70-year old with endocarditis because it's so resistant to infection. Otherwise, it's not lasting as long as the latest porcine valves and deteriorates sadly in some people. He recommended the same valve (after mechanical which was what he said he would choose for himself) that the other surgeon did, a stentless porcine.

Life is interesting...

Karen

 

[Lisa]

My homograft is 1 year, 6 months, and 6 days old...

My homograft is 1 year, 6 months, and 6 days old...

and I feel terrific! I am also 32 and not planning on having children; BUT you just never know. My recovery was pretty easy, all things considered. I had a terrible time with naseau/vomiting most of the first week following surgery but it was all uphill from there. I truly didn't know how bad I felt until after I had the operation.

Karen, I haven't posted here in quite a while, but you can search for my previous posts or email/private message and I'll answer any questions I can.

Take care and I'm most people here would agree that you'll probably keep second guessing yourself all the way up to the surgery date!