Department of Cardiac Surgery, Ludwig-Maximilians-University, University Hospital Grosshadern, Munich, Germany.
Eur J Cardiothorac Surg. 2012 Feb;41(2):404-8. doi: 10.1016/j.ejcts.2011.04.043.
Since 1992, homografts have been implanted in our institution. After initial sub-coronary implantation of the homograft, our preferred technique for aortic-valve replacement with homografts became root replacement, which poses a surgical challenge whenever redo procedures are necessary. The aim of the present study was to evaluate the outcome after homograft redo surgery, based on prospective data from the biggest patient cohort in Germany for this procedure.
Between May 1992 and August 2009, 363 adult patients underwent aortic-valve replacement with homografts in our cardiac surgery department. Homograft replacement was indicated in 90 of these 363 patients due to degenerative or infective conditions, and these were analysed.
In these 73 male and 17 female patients (mean age at redo operation 62.0 years), homograft explantation was necessary due to infection (n = 14) or degeneration (stenosis n = 19, regurgitation > II° n = 57). Mean time between homograft implantation and redo operation was 8.4 ± 3.6 years (range 0.0-15.5 years). Redo valve replacement through the aorta/homograft was done in 86 cases (valve into homograft wall = 80, total replacement of the homograft = 6) and trans-apical homograft replacement with an Edwards Sapien® Trans-catheter valve in four. Thirteen additional procedures were performed: bypass surgery (n = 1), mitral-valve repair (n = 6), replacement of the ascending aorta (n = 5) and tricuspid-valve repair (n = 1). Thirty-day mortality was 8.9% (n = 8, all of these patients presented with a homograft infection; five patients had a homograft reinfection). Survival rates after 1 and 5 years were 86.0% and 77.4%, respectively.
The risk for a redo procedure after aortic-valve replacement with a homograft seems to be acceptable when compared with other prostheses. Mortality was, however, elevated in patients with a homograft infection. Trans-apical procedures are safe and feasible and might be our preferred technique for the future. Valve infections still remain a contraindication for trans- apical procedures.
自 1992 年以来，同种异体移植物已在我院植入。在同种异体移植物进行初步冠状动脉下植入后，我们在使用同种异体移植物进行主动脉瓣置换时首选根部置换术，这在需要再次手术时带来了一定的手术挑战。本研究旨在基于德国该手术最大患者队列的前瞻性数据，评估同种异体移植物再次手术的结果。
1992 年 5 月至 2009 年 8 月，我院心脏外科共对 363 例成人进行了主动脉瓣同种异体移植物置换术。由于退行性或感染性疾病，90 例患者需要进行同种异体移植物置换术，对这些患者进行了分析。
在这 73 名男性和 17 名女性患者（再次手术时的平均年龄为 62.0 岁）中，由于感染（n=14）或退行性病变（狭窄 n=19，反流> II° n=57）需要进行同种异体移植物取出术。同种异体移植物植入与再次手术之间的平均时间为 8.4±3.6 年（0.0-15.5 年）。通过主动脉/同种异体移植物进行再次瓣膜置换术 86 例（瓣膜进入同种异体移植物壁=80，同种异体移植物完全置换=6），通过经心尖途径行 Edwards Sapien®经导管瓣膜置换术 4 例。还进行了 13 例附加手术：旁路手术（n=1）、二尖瓣修复术（n=6）、升主动脉置换术（n=5）和三尖瓣修复术（n=1）。30 天死亡率为 8.9%（n=8，这些患者均有同种异体移植物感染；5 例有同种异体移植物再感染）。1 年和 5 年生存率分别为 86.0%和 77.4%。
与其他假体相比，主动脉瓣置换后进行同种异体移植物再次手术的风险似乎可以接受。然而，同种异体移植物感染患者的死亡率较高。经心尖途径手术是安全可行的，可能是我们未来的首选技术。瓣膜感染仍然是经心尖途径手术的禁忌证。
