title: Decellularized aortic homografts for aortic valve and aorta ascendens replacement.
abstract: OBJECTIVE
  The choice of valve prosthesis for aortic valve replacement (AVR) in young patients is challenging. Decellularized pulmonary homografts (DPHs) have shown excellent results in pulmonary position. Here, we report our early clinical results using decellularized aortic valve homografts (DAHs) for AVR in children and mainly young adults.
  
  
  METHODS
  This prospective observational study included all 69 patients (44 males) operated from February 2008 to September 2015, with a mean age of 19.7 ± 14.6 years (range 0.2-65.3 years). In 18 patients, a long DAH was used for simultaneous replacement of a dilated ascending aorta as an extended aortic root replacement (EARR). Four patients received simultaneous pulmonary valve replacement with DPH.
  
  
  RESULTS
  Thirty-nine patients (57%) had a total of 62 previous operations. The mean aortic cross-clamp time in isolated cases was 129 ± 41 min. There was 1 conduit-unrelated death. The mean DAH diameter was 22.4 ± 3.7 mm (range, 10-29 mm), the average peak gradient was 14 ± 15 mmHg and the mean aortic regurgitation grade (0.5 = trace, 1 = mild) was 0.6 ± 0.5. The mean effective orifice area (EOA) of 25 mm diameter DAH was 3.07 ± 0.7 cm(2). DAH annulus z-values were 1.1 ± 1.1 at implantation and 0.7 ± 1.3 at the last follow-up. The last mean left ventricle ejection fraction and left ventricle end diastolic volume index was 63 ± 7% and 78 ± 16 ml/m(2) body surface area, respectively. To date, no dilatation has been observed at any level of the graft during follow-up; however, the observational time is short (140.4 years in total, mean 2.0 ± 1.8 years, maximum 7.6 years). One small DAH (10 mm at implantation) had to be explanted due to subvalvular stenosis and developing regurgitation after 4.5 years and was replaced with a 17 mm DAH without complication. No calcification of the explanted graft was noticed intraoperatively and after histological analysis, which revealed extensive recellularization without inflammation.
  
  
  CONCLUSIONS
  DAHs withstand systemic circulation, provide outstanding EOA and appear as an alternative to conventional grafts for AVR in young patients. EARR using DAH is a further option in aortic valve disease associated with aorta ascendens dilatation as it avoids the use of any prosthetic material.
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany tudorache.igor@mh-hannover.de.
authors.forename: Igor
authors.initials: I
authors.lastname: Tudorache
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Alexander
authors.initials: A
authors.lastname: Horke
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Serghei
authors.initials: S
authors.lastname: Cebotari
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Samir
authors.initials: S
authors.lastname: Sarikouch
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Dietmar
authors.initials: D
authors.lastname: Boethig
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Breymann
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Philipp
authors.initials: P
authors.lastname: Beerbaum
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Harald
authors.initials: H
authors.lastname: Bertram
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Mechthild
authors.initials: M
authors.lastname: Westhoff-Bleck
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Karolina
authors.initials: K
authors.lastname: Theodoridis
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Dmitry
authors.initials: D
authors.lastname: Bobylev
authors.affiliation: State University of Medicine and Pharmacy, Chisinau, Republic of Moldova.
authors.forename: Eduard
authors.initials: E
authors.lastname: Cheptanaru
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany State University of Medicine and Pharmacy, Chisinau, Republic of Moldova.
authors.forename: Anatol
authors.initials: A
authors.lastname: Ciubotaru
authors.affiliation: Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Axel
authors.initials: A
authors.lastname: Haverich
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D064591:Allografts / Q000502:physiology; D001021:Aortic Valve / Q000502:physiology / Q000637:transplantation*; D001022:Aortic Valve Insufficiency / Q000503:physiopathology / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000503:physiopathology / Q000601:surgery*; D001705:Bioprosthesis; D002648:Child; D002675:Child, Preschool; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D014184:Transplantation, Homologous / Q000379:methods; D055815:Young Adult
keywords: Aortic valve; Decellularized homografts; Valve prosthesis; Valve replacement