• Zain Khalpey, Wernard Borstlap, Patrick O Myers, Jan D Schmitto, Siobhan McGurk, Ann Maloney, and Lawrence H Cohn.
• Department of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02132, USA.
• Ann. Thorac. Surg. 2012 Sep 1;94(3):731-5; discussion 735-6.

BackgroundReoperations 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.MethodsWe 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.ResultsTwenty-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.ConclusionsThe 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.Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

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