title: The valve-in-valve operation for aortic homograft dysfunction: a better option.
abstract: BACKGROUND
  Reoperations on dysfunctional aortic homografts often require root reconstruction with coronary reanastomosis. This is associated with substantial perioperative morbidity and mortality. Resecting compromised aortic homograft valve leaflets and seating a new valve within the homograft annulus avoids root reconstruction and is a viable alternative.
  
  
  METHODS
  We retrospectively evaluated 50 patients undergoing reoperations on dysfunctional homografts between 1999 and 2011. Outcomes were compared between valve-in-valve (ViV) and aortic valve-prosthetic conduit (AVR-C) procedures.
  
  
  RESULTS
  Twenty-eight patients underwent ViV, and 22 had AVR-C. Groups were similar in age, sex, and incidence of endocarditis and renal failure. Median time between homograft and index procedure was 8.5 years for AVR-C and 8 years for ViV patients (p=0.93). Patients undergoing AVR-C had longer cardiopulmonary bypass (282 versus 151 minutes; p<0.001) and cross-clamp (207 versus 106 minutes; p<0.001) times and received significantly more intraoperative red blood cell transfusions than ViV patients (36.4% versus 7.1%; p=0.014). Patients undergoing ViV had shorter intensive care unit stays (47 hours versus 67 hours for AVR-C; p=0.049) and fewer postoperative red blood cell transfusions (21.4% versus 54.5%; p=0.020). There were trends toward shorter ventilation times for ViV patients (6 hours versus 11 hours for AVR-C; p=0.077), shorter postoperative length of stay (7 days versus 9 days; p=0.092), and fewer readmissions (3.6% versus 19.0%; p 0.073). One operative mortality occurred in the AVR-C group.
  
  
  CONCLUSIONS
  The strategy of replacing aortic valve leaflets in a failed calcified homograft, with a valve seated inside the annulus, is a safe alternative to root reconstruction. Preserving root architecture and coronary buttons facilitates shorter cardiopulmonary bypass and cross-clamp times, and directly impacts transfusions, intensive care unit time, hospital stay, and readmission rates.
authors.affiliation: Department of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02132, USA.
authors.forename: Zain
authors.initials: Z
authors.lastname: Khalpey
authors.forename: Wernard
authors.initials: W
authors.lastname: Borstlap
authors.forename: Patrick O
authors.initials: PO
authors.lastname: Myers
authors.forename: Jan D
authors.initials: JD
authors.lastname: Schmitto
authors.forename: Siobhan
authors.initials: S
authors.lastname: McGurk
authors.forename: Ann
authors.initials: A
authors.lastname: Maloney
authors.forename: Lawrence H
authors.initials: LH
authors.lastname: Cohn
mesh_terms: D000328:Adult; D000368:Aged; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000379:methods; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods* / Q000401:mortality; D006351:Heart Valves / Q000601:surgery / Q000637:transplantation*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D014184:Transplantation, Homologous / Q000009:adverse effects; D016896:Treatment Outcome; D014463:Ultrasonography