[HSF] Calcified Homograft

[G T Stavridis]

Dear Forum,

32 year old female with previous AVR (Subcoronary Homograft) and MVPlasty with a pericardial band in 1995, subsequently, in 1996, underwnt Redo AVR (new Homograft as a root inclusion) and MVRepair with 
C-E Ring and sliding plasty because of  fungal endocarditis  of the original Homograft. She remained for almost 8 years on antifungal therapy. Gradually over the years she developed modearte symptoms NYHA II.
Now her ECHO has worsened with the following findings:
LA=71mm(was 60), EDD/ESD 58/42   E`F~~50% RVEF=40%  TDI=5m/sec, AVA 0.8cm2 AVpgrad 65mmHg  3/4 MReg  and MVA 1.4cm2, PHYT.
The coronary angiography appears normal, with severe calcification of the ARoot and the prox 2/3 of the AsAo.
The CT chest in addition shows circumferential calcification of the involved Aorta.
Realizing the technical difficulties of this Redo-Redo case as far as the prox Ao is concerned, would you consider for the AVR (despite her young age) the solution of the apical valved conduit, the transapical SAPIEN or the implantation of a mechanical prosthesis at the level of midAscAo-(Hufnagel)  in addition to MVR!!!. Of course one can embark on the difficult approach of Redoing the AValve..is it easy to endarterectomize the homografted aorta in order to create a suturable area ?? is the type of calcification worse than the native porcelain aorta?? ANY OTHER IDEAS!!
Thanks in advance

G T Stavridis MD FETCS
Onassis Cardiac Surgery Ctr.
AThens GREECE