Table Of ContentCardiac Valve Allografts 1962-1987
Proceedings of the Symposium on Current Concepts on the
Use of Aortic and Pulmonary Allografts for Heart Valve
Substitutes
Berlin (West), September 7-9, 1987
A. C. Yankah, R. Hetzer, D. C. Miller,
D. N. Ross, J. Somerville,
M. H. Yacoub (Eds.)
Cardiac Valve
Allografts 1962-1987
Current Concepts on the Use of Aortic
and Pulmonary Allografts for Heart
Valve Substitutes
Steinkopff Verlag Darmstadt
Springer-Verlag New YQrk
A. Charles Yankah, M.D. Roland Hetzer, M.D. D. Craig Miller, M.D.
Consultant Professor, Chairman and Ass. Professor of Cardiac
German Heart Center Berlin Director Surgery
Clinic for Cardiothoracic Clinic for Cardiothoracic Stanford University
and Vascular Surgery and Vascular Surgery Dept. of Cardievascular Surgery
0-1000 Berlin (West) 65 German Heart Center Berlin Stanford
Germany 0-1000 Berlin (West) 65 California 94305,
Germany USA
Donald Ross, M.D. Jane Somerville, M.D. Magdi H. Yacoub, M.D.
Consultant Cardiac Surgeon Consultant Cardiologist Professor & Consultant Cardiac
Director or Surgery National Heart Hospital Surgeon
National Heart Hospital Westmoreland Street Harefield Hospital,
Westmoreland Street London WIM 8BA National Heart and Brompton
London WlM 8BA UK. Hospital, London
UK. UK.
CIP-Titelaufnahme der Deutschen Bibliothek
Cardiac valve allografts: 1962-1987; current concepts on the use of aort. and pulmonary allografts
for heart valve substitutes; [proceedings of the Symposium on Current Concepts on the Use of Aort.
and Pulmonary Allografts for Heart Valve Substitutes, Berlin (West), September 7-9, 1987] 1 A. C.
Yankah ... (eds.). - Darmstadt: Steinkopff; New York: Springer, 1988.
ISBN-13: 978-3-642-72422-0 e-ISBN-13: 978-3-642-72420-6
DOl: 10.1007/978-3-642-72420-6
NE: Yankah, A. C. [Hrsg.]; Symposium on Current Concepts on the Use of Aortic and Pulmonary
Allografts for Heart Valve Substitutes < 1987, Berlin, West>
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Foreword
It was the genius of Gordon Murray in Toronto that introduced the use of allografts
into cardiac surgery in the 1950s. Soon after this on opposite sides ofthe world, Sir
Brian Barratt-Boyes in Auckland, New Zealand, and Mr. Donald Ross in London,
undertook to use allografts for the replacement of diseased aortic valves. Since that
time the global interest in allografts has been patchy, episodic, and without a con
sensus. Nonetheless, for the last 20 years at least three groups in the world have
steadfastly pursued the development of new and relevant information concerning
the use of allograft valves in humans. These are the centres of Sir Brian Barratt
Boyes, Mr. Donald Ross, and Mark O'Brien in Brisbane. More recently, talented
investigators, including Drs. Yankah, Yacoub, and others, have been developing
information concerning the immunological aspects of the use of allografts, as well
as their clinical use. No doubt, at present, cardiac valve allografts of one sort or
another are the devices of choice for conduits and have an important place in the
surgery of aortic valve replacement. Even so, in the mind of this writer at least, the
future usefulness of allografts for the replacement of diseased cardiac valves and
conduits between a ventricle and the pulmonary artery, remains problematic, and
depends upon improvements in other devices for this purpose and upon improve
ments that may be made in preparing and using allografts.
The question for the future, then, is whether developments in bioprostheses and
mechanical valves will eventuate in devices so superior to those currently available
that there will be little or no place for the logistically and technically more difficult
task of using allograft valves. Improvements may be made in the performance and
behavior of allograft valves as well, of course, but it seems less likely that these will
result in dramatic improvements.
This book brings together the most important current work in this interesting and
always changing field. Dr. Yankah and his colleagues are to be congratulated for
conceiving the idea of this project and providing such an important scientific stim
ulus to it. Careful study of this book will provide timely and important information
for the reader.
John W. Kirklin
v
Preface
In the face of the very limited experience we had, as compared to the other centers,
the German Heart Center organized this Symposium on the current concepts on the
use of aortic and pulmonary allografts for heart valve substitutes in Berlin from
Sept. 7-9, 1987 most egoistically, with the primary aim of learning as much as
possible from the great number of experts with much larger experience and knowl
edge in this field. The Symposium also marked the 25th anniversary of the first
clinical use of aortic valve allograft in the subcoronary position, a pioneer work
which was achieved by two prominent surgeons, Mr. Donald N. Ross, Senior Sur
geon, National Heart Hospital, London, UK and Sir Brian Barratt-Boyes, Surgeon
in-Chief, Green Lane Hospital, Auckland, New Zealand, who were the honorary
guests at the meeting. We congratulate Dr. Gordon Murray who paved the way,
experimentally and clinically in the 1950s to this success. We consider the devel
opment of this particular field as exemplary for cardiac surgery on the whole, where
after various technical developments and changing opinions in preservation tech
niques and immunological aspects, the original method has survived with greater
and better understanding, with more precise indications and the possibility of reli
able comparison.
The symposium as its theme suggests, was exclusively devoted to the use of cardiac
valve allografts in the sub coronary and pulmonary positions. The use of allografts
in the mitral and tricuspid positions was cautiously discussed but not in detail.
The Berlin symposium which took place during the 750th anniversary of the city of
Berlin, brought together cardiologists, cryobiologists, engineers, pathologists, prac
titioners and surgeons from Austria, Australia, Belgium, People's Republic of China,
France, the Federal Republic of Germany, German Democratic Republic, Hungary,
Italy, Netherlands, Portugal, Poland, Spain, Taiwan, R.O.C., United Kingdom, USA
who listened to the 41 presentations and a panel discussion over 2 days and partic
ipated actively in the lively discussions.
The live video transmission of subcoronary transplantation of aortic allograft from
the operating room of the German Heart Center to the International Congress Cen
ter Berlin where the faculty of experts answered questions from the audience and
elaborated on the surgical techniques, was accepted as an interesting new way of
scientific communication.
Opportunity was given to surgeons who were interested in using allograft valves for
valve replacement, on their return home, to practice the transplantation techniques
under the supervision of allograft experts, during the special laboratory session pro
vided by the organizers.
Now that the interest in allograft surgery is growing, the problems of procuring
adequate donor allografts of different sizes arise.
Currently, our major source of allograft valve harvesting is from the recipients'
hearts at the time of cardiac transplantation. We have now performed 93 heart
transplantations since April 1986 here in Berlin. This shows the number of valves
we could have at our disposal. Organized regional procurement centers in collabo
ration with organ transplant centers, intensive ease and trauma units might help in
developing regional or hospital-based allograft valve banks.
VII
It was most appropriate to start the Symposium with Mr. Donald N. Ross, London
and let it end with Sir Brian Barratt-Boyes who have contributed continuously and
scientifically to the "state of the art". The faculty members were very cooperative
with the collection of the manuscripts. The editing of this book has been a chal
lenging and memorable experience without constraints and we are very happy being
able to present the proceedings within such a short time after the symposium.
We would also like to thank the members of the editorial board for their cooperation.
Finally, but not least, we are greatly indebted to the City of Berlin, Mrs. Roder and
her hard-working team and all the sponsors who provided the funds to make this
symposium possible.
This book entails the work of cryobiologists, immunologists, pathologists, cardiol
ogists and surgeons who are experts on cardiac valve allografts and it was a great
pleasure to host the Berlin Symposium, and we hope that the reader will get more
valuable information out of the proceedings for the benefit of his patients.
Berlin, December 1987 Roland Hetzer
A. Charles Yankah
VIII
To our families and loved ones,
whose religious understanding of the demands
of our surgical and scientific lives
made this book possible.
IX
Mr. Donald N. Ross Sir Brian G. Barratt-Boyes
Senior Surgeon Surgeon-in-chief
National Heart Hospital Green Lane Hospital
London, U.K. Auckland, New Zealand
The two pioneer surgeons who independently and successfully inserted the first
aortic allografts in the subcoronary position in June and August 1962.
x
Contents
Foreword
J. W. Kirklin . ............... ...... .... ...... ... ... .... ..... ..... ................ ... ...... .... ..... .......... ...... V
Preface
R. Hetzer, A. C. Yankah ................................................................................... VII
Faculty, contributors and invited discussants ....... .... ... ... .... .... .... ... ....... ... ... .... ... XV
Honorary guest lecture
Evolution of the biological concept in cardiac surgery: A Pilgrim's Process
D. N. Ross ........................................................................................................ .
Procurement and preservation techniques
I
Allogeneic valve procurement in cardiac transplantation
S. SchUler, A. C. Yankah, R. Hetzer ................................................................. 13
Antibiotic sterilisation in the preparation of homovital homograft valves:
Is it necessary?:
L. Gonzalez-Lavin, L. McGrath, M. Alvarez, D. Graf .................................... 17
Procurement and viability of cardiac valve allografts
A. C. Yankah, R. Hetzer ................................................................................... 23
Cryobiology of tissues
S. R. May, J. G. Baust ....................................................................................... 27
Cryopreservation of aortic valve homografts
J. K. Kirklin, J. W. Kirklin, A. D. Pacifico, S. J. Phillips ................................ 35
Factors affecting the viability of cryopreserved allograft heart valves
A. E. Heacox, R. T. McNally, K. G. M. Brockbank ......................................... 37
Endothelial and fibroblast viability assays for tissue allografts
H. L. Bank, M. K. Schmehl, K. G. M. Brockbank ........................................... 43
Discussion . ...... ........ ....... ..... ...... ..... .......... .... ...... ...... ......... ..... ........ ........ .... ........ 49
Contributions for discussion:
Problems of homograft procurement
A. L. Moulton .................................................................................................... 52
Heart valve procurement in Berlin
F. Keller, A. C. Yankah, S. SchUler, R. Klan, G. Offermann, H. Warnecke,
R. Hetzer .... ..... ............ .... ...... ..... .... ...... ...... .... ........... ...... .................. ... ... .... ...... 55
Transplantation immunology of heart valve allografts
Basic principles of transplantation immunology
W. Miiller-Ruchholtz ......................................................................................... 59
XI
