Table Of ContentCardiac Reconstructions with
Allograft Tissues
Springer
New York
Berlin
Heidelberg
Hong Kong
London
Milan
Paris
Tokyo
Cardiac Reconstructions
with Allograft Tissues
Richard A. Hopkins, MD
Karl E.Karlson,MD,and Gloria A.Karlson,MD,Professor
and Chief,Cardiothoracic Surgery,Brown University School
of Medicine;Cardiac Surgeon-in-Chief,Rhode Island
Hospital,The Miriam Hospital,and Hasbro Children’s
Hospital;and Director,Collis Cardiovascular Research
Laboratory,Providence,Rhode Island
With 437 images,11 in Full Color
Illustrations by Thomas Xenakis
3
Richard A.Hopkins,MD
Karl E.Karlson,MD,and Gloria A.Karlson,MD,Professor and Chief,Cardiothoracic
Surgery,Brown University School of Medicine;Cardiac Surgeon-in-Chief,Rhode
Island Hospital,The Miriam Hospital,and Hasbro Children’s Hospital;and Director,
Collis Cardiovascular Research Laboratory,Providence,RI,USA
Library of Congress Cataloging-in-Publication Data
Hopkins,R.A.(Richard A.)
Cardiac reconstructions with allograft tissues / by Richard A.Hopkins,and 56
contributors;illustrations by Thomas Xenakis.
p. ; cm.
Cardiac reconstructions with allograft valves.c1989.
Includes bibliographical references and index.
ISBN 0-387-94962-3 (alk.paper)
1. Heart valves—Surgery. 2. Homografts. I. Hopkins,R.A.(Richard A.).
Cardiac reconstructions with allograft valves. II. Title.
[DNLM:1. Heart Valves—transplantation. 2. Cryopreservation. 3. Tissue
Transplantation. 4. Transplantation,Homologous.WG 169 H795ca 2003]
RD598.C3435 2003
617.4¢120592—dc22 2003059130
ISBN 0-387-94962-3 Printed on acid-free paper.
© 2005 Springer Science+Business Media,Inc.
All rights reserved.This work may not be translated or copied in whole or in part without
the written permission of the publisher (Springer Science+Business Media, Inc., 233
Spring Street,New York,NY 10013,USA),except for brief excerpts in connection with
reviews or scholarly analysis.Use in connection with any form of information storage
and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed is forbidden.
The use in this publication of trade names,trademarks,service marks,and similar terms,
even if they are to be taken as an expression of opinion as to whether or not they are
subject to proprietary rights.
While the advice and information in this book are believed to be true and accurate at
the date of going to press,neither the authors nor the editors nor the publisher can accept
any legal responsibility for any errors or omissions that may be made.The publisher
makes no warranty,express or implied,with respect to the material contained herein.
Printed in the United States of America. (BS/MVY)
9 8 7 6 5 4 3 2 1 SPIN 10553102
springeronline.com
To Jenny,Kirstin,Tristan,and Devon
Preface
This volume is a follow-up to the book Cardiac Reconstructions
with Allograft Valves, which was written with five contributors and
an outstanding artist.Since its publication in 1989,the information in
this field has increased dramatically, paralleling the increased clinical
use of cardiovascular allograft tissues.Many new techniques have been
developed and refinements of the older techniques have been pub-
lished based on the experiences of many surgeons.In addition,the fun-
damental biology of valve transplantation and especially the use of
cryopreservation to facilitate transplantation, has been a major focus
of research.Thus,much more is known about these tissues than at the
time of the writing of the first book. Because of this progress, a new
volume seemed appropriate. Because cryopreserved cardiovascular
tissues are also used without valves for many important reconstruc-
tions, I decided to expand the focus of the book, and thus the slight
modification in the title. More than two-thirds of this book is new
material.
The book has also undergone another fundamental change.While the
first edition was predominantly written by the main author,to include
much of the available knowledge in this field, this new edition man-
dated a contributor format.These experts explore the fundamental sci-
entific basis of this field which is critical to an understanding of allograft
tissues.Most sections have been rewritten to reflect increased clinical
and research experience.
Other important additions include a special section on biochemical
and morphologic studies of explanted experimental animal and clinical
human valves.Because many of the fundamental clinical concepts are
based on the experience of a relatively small number of centers actively
transplanting homografts in the 1970s and early 1980s,I solicited sum-
marized versions of results from the surgeons and their colleagues who
contributed importantly to this early phase (Chapter 2–7).The basic cell
biology of these tissues has been investigated by a number of focused lab-
oratories (including our own),requiring complete revisions and expan-
sions of the relevant chapters (8–30).Cryopreservation protocols have
matured based on significant research,thus mandating a major rewriting
of Section VIII by the authors from LifeNet Tissue Services.
vii
viii Preface
The information presented firmly resolves the question of chronic
interstitial leaflet cell viability following cryopreserved cardiac valve
allotransplantation—the nails are driven into the coffin of the pro-
longed cell survival theory. An alternative theory for how and why
homografts actually perform so well is presented based on significant
laboratory and human data.The resolution of the conflicting theories
of prolonged cell viability following cardiac valve transplantation is
summarized in Chapter 20.This biology is a fascinating but constantly
moving target.As biological modifications ensue with genetic,molecu-
lar and cellular manipulations of these allograft tissues,these will be an
ever-expanding need for the surgical techniques of cardiac reconstruc-
tions described in this book.
Allograft tissue transplants are increasingly used by all cardiac sur-
geons,but are particularly important for pediatric patients as a conse-
quence of special advantages in highly complex congenital lesions.The
availability of cryopreserved allografts has initiated a wave of surgical
creativity which is reflected in the marked expansion of the chapter on
left ventricular outflow tract reconstructions, especially for complex
neonatal problems.The growing role for autologous valve transplant
procedures (e.g.,Ross operations) in both children and adults has man-
dated marked expansion of the techniques depicted.Many new surgi-
cal methods are described,and older techniques have been refined.In
addition,surgical techniques used with allografts are also applicable to
unstented xenografts, so new sections have been added to depict the
evolution of ventricular outflow tract reconstruction from root replace-
ments,through “miniroots”and autografts,to the implantation methods
for unstented xenografts.
As in the first edition, certain conventions are used. Half-tone or
carbon dust figures are used to depict surgical techniques as viewed
from the surgeon’s perspective.Repetition of steps in the depiction of
various surgical techniques spares the reader the need to flip pages.The
terms “homograft” and “allograft” are used interchangeably as no
purpose is served by a pedantic argument about which is more correct
today.
All surgeons performing pediatric and/or adult valve replacements
and reconstructive cardiac surgeries should be interested in these
methods.Cardiothoracic residents and cardiologists will find the volume
useful. Most of the surgical techniques have been used by me.When
contributors’ techniques vary from my own,I have noted optional varia-
tions or have noted my preferences.Refinements are based on my own
personal experience exceeding 600 allograft and autograft reconstruc-
tions spanning the age spectrum of premature neonates to adults in their
seventh decade,and now including shuntless valves.
Cryopreserved allograft tissues are now standard materials for the
reconstructive cardiac surgeon. Surgical reconstructive methods con-
tinue to be refined and new approaches developed.Both surgical tech-
niques and notions about the nature of this tissue we are transplanting
have evolved.Putting all of this into perspective required the addition
of a thirteenth section “Future Directions”with the intent of creating
a critical rationale for valve replacement choice and to suggest future
Preface ix
directions for basic and applied research,just at the start of a new era
based on bioengineering which will involve decellularized and recellu-
larized valves.For surgeons facing challenging cardiac reconstructions,
an enhanced understanding of the biological/material properties of
allografts and a broadening of the range of surgical techniques for
which these are applicable,are the fundamental purposes of this book.
Richard A.Hopkins,MD
Spring 2004
Providence,RI
Acknowledgments
This work could not have been finished without the help of numerous
people.First,the collaboration with Tom Xenakis,the illustrator,con-
tinues to be a superb intellectual exercise,and his contributions cannot
be over emphasized.The clarity of his interpretation of the surgeon’s
manipulations is unparalleled.The 1989 allograft book garnered many
compliments from colleagues on the beautiful artwork that always
seemed to emphasize just the right points.The collaboration with sci-
entists in my laboratory as well as others from around the world has
been critical to furthering my own understanding of the biology of
these tissues.Especially important to this process were my Georgetown
PhD students who all are now accomplished surgeons: Drs. Messier,
Domkowski,and Myers.Dr.Steven Hilbert and his colleague,Dr.Fred
Schöen,have maintained the focus on the explant pathology of these
tissues,which has contributed greatly to the understanding of allograft
valve transplant biology by the surgical community. Dr. Hilbert has
been a friend and colleague for 20 years and an astute collaborator,
especially as we enter the era of bioengineered heart valves,the next
phase of valve transplants.I acknowledge the skill and contribution of
all of the surgical contributors. Many of the surgeon coauthors are
members of the August Lunar Society for Congenital Cardiac Surgery,
which has been a forum for the evolution of some of the techniques
described. I am appreciative for the dedicated research collaboration
with LifeNet,an institution of high integrity dedicated to saving lives
with expertly procured and prepared tissues and organs,and especially
the collegiality and professionalism of Perry Lange and Lloyd
Wolfinbarger,PhD.
Dr. Arthur Bert is a cardiac anesthesiologist of world-class skill,
whose superb care of our patients and talented interest in periopera-
tive TEE for reconstructive cardiac surgical lesions has contributed
greatly to the excellent outcomes enjoyed by our patients needing
complex reconstructive cardiac surgery, and who’s ability to image
functioning allograft valves has been valuable clinically and in the
laboratory.
Alan M. Gilstein and William H.D. Goddard co-chaired a cardiac
fundraising campaign for our hospitals, Rhode Island Hospital, The
xi
