Decellularized Fresh Pulmonary Homografts for Pulmonary Valve Replacement in Ross Patients: A Promising Solution for the Double-Valve Problem in Adolescents and Young Adults

Background: Surgical interventions on both the autograft and on pulmonary valve substitute are a common problem in adolescents and young adults after Ross operation using the free-root replacement technique. The double-valve involvement presents a burden for wider use of Ross operation in this age group. We report our initial experience with the modified subcoronary Ross operation using decellularized fresh pulmonary homografts (DPH) for primary pulmonary valve replacement. Additionally, the use of DPH for secondary surgical pulmonary valve replacement in patients after Ross operation is presented.

Method: Between November 2018 and August 2021, we have offered DPH allocation to selected adolescents and adults expected to receive an adult-sized pulmonary valve substitute during Ross operation. Adolescents after Ross operation scheduled for secondary pulmonary valve replacement preferably received implantation of DPH. After a successful allocation, the personalized DPH was processed and stored at 2 to 8°C prior to surgery.

Results: Primary implantation of DPH during subcoronary Ross operation was performed in 7 patients. Another three adolescents received secondary DPH implantation after previous free-root Ross operation. The median age at DPH implantation was 14.5 years (IQR: 9.25–16). The median normal pulmonary valve diameter (z-score: 0) of the recipients was 23 mm (IQR: 20.3–27.3). Implanted DPH median diameter was 27 mm (range: 26.3–28.8). The valves were oversized up to a median z-score of 1.3 (IQR: 0.6–1.8). Median time spent on DPH waiting list (from valve order until valve release by the manufacturer) was 60 days (IQR: 28.5–89.5). The distal homograft anastomosis was performed in everting technique to prevent constriction. The technical feasibility of the procedure was excellent. On postoperative echocardiography, DPHs showed optimal function with a maximum of mild regurgitation and no significant transvalvar gradient in all patients. The early clinical outcome was uneventful and patients were discharged after a median of 7 days (IQR: 6–7). All patients were kept on anti-platelet-aggregation agents for a minimum of 6 months.

Conclusion: The primary implantation of DPH during subcoronary Ross operation, as well as secondary DPH implantation after any Ross operation in adolescents and young adults is feasible. A wider use of this technique could evolve to a promising solution for the double-valve problem in this patient group.

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Artikel online veröffentlicht:
03. Februar 2022