Aortic valve replacement with allograft/autograft: subcoronary versus intraluminal cylinder or root

From April 1990 to May 1994, 89 patients (median age, 42 years; range, 10 days to 66 years) underwent aortic valve or root replacement with allografts or autografts. Thirteen patients were less than 18 years old at the time of operation. Indication for aortic valve replacement was aortic stenosis (50 patients, 56%), small stenotic prosthesis (2 patients, 2%), aortic valve endocarditis (19 patients, 21%), isolated aortic regurgitation (17 patients, 19%), and type II truncus arteriosus (1 patient, 1%). The subcoronary implantation was used in 45 patients (group A), and implantation of an intraluminal cylinder (16 patients) or complete root replacement (28 patients) was performed in the remaining 44 patients (group B). The Ross procedure was performed in 22 patients. Intraoperative transesophageal echocardiography was used routinely. Five patients died in the early postoperative period (6%), 2 in group A and 3 in group B. Three other patients required immediate replacement of a failing graft by a mechanical prosthesis (1 in group A and 2 in group B). There has been no late death. All survivors remained in New York Heart Association functional class I and were free of thromboembolic complications. Endocarditis occurred in 2 patients, 1 year after operation. Both were successfully treated medically. Echocardiographic studies were obtained serially in every patient. Four patients, 2 in group A and 2 in group B underwent reoperation because of mild-to-moderate aortic regurgitation (rate of reoperation, 5%). Two valves were repaired and two were replaced by an allograft. At late echocardiographic follow-up (up to 4 years postoperatively), 22 of 42 patients in group A and 6 of 39 patients in group B showed some degree of aortic regurgitation by color Doppler (p < 0.001). The mean postoperative transvalvular gradient was 12 mm Hg in group A and 6 mm Hg in group B (p < 0.001). It is concluded that aortic valve replacement with either an allograft or an autograft can be performed in both children and adults with a low morbidity and mortality, yielding excellent hemodynamic results. It is suggested that the implantation of an intraluminal cylinder and the complete root replacement might be superior to the subcoronary technique as they result in lower transvalvular gradients and less valvular regurgitation.