Replacement of the Aortic Root with a Pulmonary Autograft in Children and Young Adults with Aortic-Valve Disease

BACKGROUND: The optimal substitute for severely diseased aortic valves in children and young adults is unknown. The use of a mechanical prosthesis requires permanent treatment of the patient with anticoagulants and is associated with thromboembolic and hemorrhagic complications. Aortic-valve allografts and porcine bioprostheses, which do not necessitate anticoagulant therapy, may deteriorate and have limited durability. METHODS: We therefore evaluated the use of the autologous pulmonary valve (i.e., the patient's own pulmonary valve) and the adjacent pulmonary artery as a replacement for the aortic valve and aortic sinuses in 33 patients. Five of the patients were from 8 to 16 years of age, and 28 were from 20 to 47 years of age. The pulmonary valve and the main pulmonary artery were used to replace the diseased aortic valve and the adjacent aorta. The coronary arteries were detached from the aorta and implanted into the pulmonary artery. The pulmonary valve and artery were replaced with a cryopreserved pulmonary allograft. RESULTS: There were no deaths during follow-up of up to 48 months (mean, 21 months). There were no episodes of infective endocarditis, and no reoperations on the aortic root were necessary. Also, there was no evidence on echocardiography of progressive dilatation of the autografts. With color-flow Doppler imaging, 22 patients were found to have only trivial regurgitation or none, 9 patients to have mild regurgitation, and no patients to have moderate or severe regurgitation across the autograft at the most recent follow-up visit. The mean peak velocity of flow across the autograft was 1.3 m per second (upper limit of normal, 1.8), indicating the absence of stenosis. One patient required reoperation for stenosis of the pulmonary allograft. CONCLUSIONS: Although the pulmonary-autograft procedure is more complex than simple aortic-valve replacement, it has been safely applied in selected patients, including young adults. Intermediate follow-up indicates satisfactory function of the autografts, with no dilatation or progressive valvular regurgitation. Pulmonary-root autografts may thus be the best available substitute for diseased aortic valves in children and young adults.