Root Replacement for All Allograft Aortic Valves: Preferred Technique or Too Radical? Mark F. O’Brien, FRACS, R. Stewart Finney, MD, E. Gregory Stafford, FRACS, Michael A. H. Gardner, FRACS, Peter G. Pohlner, FRACS, Peter J. Tesar, FRACS, Andrew D. Cochrane, FRACS, Kenneth L. Gall, BApplSc, and Susan E. Smith, BSc Department of Cardiac Surgery, The Prince Charles Hospital, Brisbane, Australia From November 1985 to January 1994, 146 patients have received a viable cryopreserved allograft for aortic root replacement. The follow-up was complete, with all events included to March lst, 1994. The median age of patients was 49 years; 83.6% were male. Valve dysfunc- tion (91 patients), primary aortic wall disease (45 pa- tients), and a combination of both (10 patients) were the indications for aortic root replacement. The current op- erative mortality is 1.7% (three deaths in 172 patients to July lst, 1994). Four late deaths have occurred, with an &year actuarial survival of 85% + 8% (95% confidence limits). Endocarditis (two events) and thromboembolism (four events) had a low incidence. Structural deteriora- A llografts have been used for aortic valve and root replacement for many years. The concept is not new and emanates from the first use of a prosthetic conduit in 1968 [l]. The need to avoid a prosthetic conduit and valve in some patients, coupled with the presence of certain pathologies of primary ascending aorta wall dis- ease, massive destruction of the valve annulus by endo- carditis, and severe congenital aortic valve annular and left ventricular outflow tract obstruction, saw the use of the allograft as a device for proximal ascending aorta and aortic root replacement (ARR). This has entailed coro- nary artery reimplantation as pedicle or side-to-side anastomoses. Many reports testify to the successful short-term and intermediate-term results 12-51. This analysis from The Prince Charles Hospital encompasses an S-year experience of 172 patients having ARR, at- tempts to justify the operation as the best technical option for the use of the allograft, and compares the results of the first 146 patients to January 1994 with those after subcoronary (493 patients) and intraaortic cylinder (41 patients) allograft implantation. Material and Methods From November 1985 to January 1994, 146 patients have had ARR with a viable cryopreserved allograft valve. Follow-up extended to March lst, 1994, the final date for Presented at the VI Intrrnational Symp<>5ium on Cardiac Bioprwthc,w<, Vancouver, BC, Canada, July 2Y-31, lYY-1. Address reprint requests to Dr O’Brien, The Prince Charles Ho<pitaI, Rode Rd, Chermsidr, Brisbane 4032, Australia. tion (three events) and reoperation for all causes (nine events) have constituted low morbidity and are com- pared wifh the results after nonroot allograft implanta- tion techniques. The clinical and echocardiographic evi- dence indicates that the immediate results of valve function with root replacement are superior. But no statistical difference between aortic root replacement and nonroot procedures is apparent at 8 years, indicating that a longer follow-up is required before the answer to the question “preferred technique or too radical” can be answered. (Ann Thorac Surg 1995;60:S87-91) the inclusion of events. This follow-up was complete with a minimum of 2 months and a maximum of 8.1 years. The median age was 49 years (range, 13 to 75 years) and 83.6% (122 patients) were male. Associated procedures were performed on 6 patients (4.1%). Ninety-one patients had allograft ARR for primary native valve dysfunction. Thirteen of these patients had their first allograft at reoperation. Primary ascending aortic wall disease was the indication for operation in 45 patients and 10 patients had combined aortic wall and valve disease. Although a total root replacement was performed on all patients, the technique evolved over the 8 years of experience. In some of the earlier operations, the coro- nary artery anastomoses were side-to-side without but- ton or pedicle formation [6, 71. In addition, the proximal suture line initially incorporated strips of Dacron felt and was performed with interrupted mattress sutures. Sub- sequently, an intermittent continuous suture was used until finally a simple continuous suture of the proximal anastomosis and coronary artery pedicle anastomosis formed the present standard technique [8]. No felt or glue is now used. With the prior knowledge of the host aortic valve annular and sinotubular diameters from echocardiography or aortography, it is now customary to select, thaw, trim, and inspect the allograft for final acceptance before establishing routine cardiopulmonary bypass. Postoperatively, most of the 143 surviving patients had an echocardiographic study before hospital discharge. While it was the policy to repeat the study every I to 2 0 1995 by The Society of Thoracic Surgeons 0003-4975/95/$9.50 0003-4975(95)00246-H