title: Structural degeneration of pulmonary homografts used as aortic valve substitute underlines early graft failure.
abstract: OBJECTIVE
  The limited availability of donor valves and experimental evidence that pulmonary valves can withstand systemic pressure made us use cryopreserved pulmonary homografts as aortic valve substitutes. We observed a high incidence of early reoperation because of severe graft insufficiency due to cuspal tears. The mid-term results are evaluated in this study and histological analysis of explanted homografts is performed to investigate the cause of graft failure.
  
  
  METHODS
  From December 1991 to April 1994, 16 patients (13 male; mean age 37.3 years, range 21-59 years) underwent aortic valve replacement with a cryopreserved pulmonary homograft. The indication was endocarditis (n = 4), bioprosthesis degeneration (n = 3) or congenital aortic valve disease (n = 9). All homografts were implanted freehand in the subcoronary position. All patients were contacted for follow-up and recent echo-Doppler studies were reviewed. Six explanted homografts were examined microscopically using routine histological techniques to analyze changes in cell population, collagen and elastic fiber structure.
  
  
  RESULTS
  Follow-up was complete in all patients. Reoperation was required in ten patients because of severe graft incompetence (mean implantation time 5.9 years, range 2.8-8.0 years). In two patients, recurrent endocarditis was the cause of graft failure. In the other eight patients the leaflets looked pliable and thin with gross tearing in one or more cusps. The histopathologic changes observed were remarkably similar in all examined grafts: the cusp tissue was almost non-cellular and the collagen fiber structure had mostly disappeared. At the site of rupture, the tissue had become thin with strongly degenerated collagen and elastic fiber structure. In the six patients with a homograft remaining in situ, echo-Doppler showed trivial to mild insufficiency in five cases and moderate to severe in one case, whereas no significant gradients were observed.
  
  
  CONCLUSIONS
  We concluded that structural reduction of cell number and degenerative alterations in the molecular composition of the extracellular matrix in valve tissue is the main cause of early graft failure in this series. The use of cryopreserved pulmonary homografts in the systemic circulation is therefore not advised.
authors.affiliation: Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands. d.r.koolbergen@lumc.nl
authors.forename: Dave R
authors.initials: DR
authors.lastname: Koolbergen
authors.forename: Mark G
authors.initials: MG
authors.lastname: Hazekamp
authors.forename: Emile
authors.initials: E
authors.lastname: de Heer
authors.forename: Frans
authors.initials: F
authors.lastname: van Hoorn
authors.forename: Hans A
authors.initials: HA
authors.lastname: Huysmans
authors.forename: Jan A
authors.initials: JA
authors.lastname: Bruijn
authors.forename: Robert A E
authors.initials: RA
authors.lastname: Dion
mesh_terms: D000328:Adult; D001021:Aortic Valve; D001705:Bioprosthesis; D015925:Cryopreservation; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D011475:Prosthesis Failure; D011664:Pulmonary Valve / Q000473:pathology / Q000637:transplantation*; D012086:Reoperation