Objective: Aortic homografts offer many advantages over prosthetic valves. However, homograft dysfunction due to degeneration or infection may lead to reoperation. Aortic valve replacement in patients who have undergone previous aortic root replacement with an aortic homograft remains a technical challenge. To assess reoperation events a retrospective review was conducted. Materials and methods: From January 2000 to October 2006, 20 consecutive patients (38.8 AE 14.9 years old) underwent repeat surgery for aortic homograft failure. Results: Reoperation was performed 7.2 AE 3.5 years after implantation of the aortic homograft as a root. Indication was homograft degeneration (n = 18 [90%]) and endocarditis (n = 2 [10%]). In patients with major homograft wall calcifications or endocarditis, nine aortic root reconstructions were performed (Bentall procedure n = 7; homograft implantation n = 2). Each homograft was dissected with electrical cauterization and removed 'en-bloc' sparing the coronary buttons. In case of flexible homograft wall, stented prostheses (mechanical n = 10, bioprosthesis n = 1) were implanted along the homograft annulus. Additional procedures consisted of mitral valve replacements (n = 8), tricuspid repairs (n = 4), Konno procedure (n = 1) and coronary bypass (n = 5). Perioperative complications occurred in seven (35%) patients: sternal re-entry accident (n = 2); reoperations for mediastinitis (n = 1) or bleeding (n = 2); renal insufficiency (n = 1); total heart block (n = 1). No association was found between operative procedures and postoperative complications (Fisher's exact test). Two patients (10%) died from multiorgan failure in the early postoperative period. In total, 94.4% of the survivors remained free from reoperation at 74 months. Conclusion: Reoperation on patients with an aortic homograft as a root presents a relatively high perioperative morbidity. The surgical strategy depends on the degree of homograft wall calcification. #

Our study neither detected cTnI elevations nor echocardiographic abnormalities suggesting significant myocardial involvement during rheumatic fever. Congestive heart failure was always associated to severe valve regurgitation.

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Rheumatic heart disease (RHD) has a worldwide prevalence of 33 million cases and 270 000 deaths annually, making it the most common acquired heart disease in the world. There is a disparate global burden in developing countries. This case report aims to address the minimal RHD coverage by the international medical community. A Tahitian boy aged 10 years was diagnosed with advanced heart failure secondary to RHD at a local clinic. Previous, subtle symptoms of changes in handwriting and months of fever had gone unrecognised. Following a rapid referral to the nearest tertiary centre in New Zealand, urgent cardiac surgery took place. He returned home facing lifelong anticoagulation. This case highlights the RHD burden in Oceania, the limited access to paediatric cardiac services in countries where the RHD burden is greatest and the need for improved awareness of RHD by healthcare professionals, and the general public, in endemic areas.

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