Extended aortic root replacement with a long DAH
In 18 patients, with associated dilatation of the ascending aorta, extended aortic root replacement (EARR) with a long DAH was performed to avoid the use of any vascular prosthesis. Characteristics are summarized in Table 2.
In this subgroup, the mean diameter of the DAH at implantation was 25.8 ± 1.8 mm resulting in a mean EOA of 3.2 ± 0.6 cm2, an average peak gradient at the latest follow-up (mean: 1.9 ± 1.2 years, total 31.1 years) of 9.4 ± 4.9 mmHg and a mean aortic regurgitation grade of 0.6 ± 0.3 (0 = none, 0.5 = trace and 1 = mild). The last mean LVEF was 61.7 ± 7.3% and the LV EDVi was 81 ± 16 ml/m2 BSA. Aortic valve z-values were 1.1 ± 0.8 at implantation and 0.9 ± 0.8 at the last follow-up. No dilatation was observed at any level of the graft (annulus, sinus of Valsava, sinotubular junction or at the level of the main pulmonary artery) during follow-up so far.
One of these was a patient who had a Ross procedure, who experienced a rapidly failing autograft and therefore underwent secondary autograft replacement using a mechanical valve in combination with aortic root repair using a conventional homograft in an overseas institution. Ten years later, he developed bacterial endocarditis with critical stenosis of the homograft used for pulmonary valve replacement during the initial Ross procedure. Because of the concomitant severe calcification of the aortic allograft used during the second operation to replace the ascending aorta and the patient's wish to cease anticoagulation therapy, the pulmonary valve, the aortic valve and the ascending aorta were replaced by decellularized allografts in one operation (Fig. 6). Three years after the operation both grafts show no signs of degeneration, there is no dilatation of the ascending aorta and the patient is free from anticoagulation therapy.
Figure 6: Preoperative aspects of the severely calcified and stenotic conventional pulmonary homograft and calcified dilated aortic bulbus in a Ross patient are shown in the first row. The second row shows the intraoperative aspect after double valve replacement with decellularized homografts including EARR by a long DAH and CMR images after 14 months.
In 4 patients, double valve replacement with DAH and DPH was performed in total.