The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.
The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.
1: J Heart Valve Dis 2001 May;10(3):334-44; discussion 335
The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve
replacements.
O'Brien MF, Harrocks S, Stafford EG, Gardner MA, Pohlner PG, Tesar PJ, Stephens
F.
The Prince Charles Hospital and the St Andrew's Hospital, Brisbane, Queensland,
Australia.
BACKGROUND AND AIM OF THE STUDY: The study aim was to elucidate the advantages and limitations of the homograft aortic valve for aortic valve replacement over
a 29-year period.
METHODS: Between December 1969 and December 1998, 1,022
patients (males 65%; median age 49 years; range: 1-80 years) received either a
subcoronary (n = 635), an intraluminal cylinder (n = 35), or a full root
replacement (n = 352). There was a unique result of a 99.3% complete follow up
at the end of this 29-year experience. Between 1969 and 1975, homografts were
antibiotic-sterilized and 4 degrees C stored (124 grafts); thereafter, all
homografts were cryopreserved under a rigid protocol with only minor variations
over the subsequent 23 years. Concomitant surgery (25%) was primarily coronary
artery bypass grafting (CABG; n = 110) and mitral valve surgery (n = 55). The
most common risk factor was acute (active) endocarditis (n = 92; 9%), and
patients were in NYHA class II (n = 515), III (n = 256), IV (n = 112) or V (n =
7).
RESULTS: The 30-day/hospital mortality was 3% overall, falling to 1.13 +/-
1.0% for the 352 homograft root replacements. Actuarial late survival at 25
years of the total cohort was 19 +/- 7%. Early endocarditis occurred in two of
the 1,022 patient cohort, and freedom from late infection (34 patients)
actuarially at 20 years was 89%. One-third of these patients were medically
cured of their endocarditis. Preservation methods (4 degrees C or
cryopreservation) and implantation techniques displayed no difference in the
overall actuarial 20-year incidence of late survival endocarditis,
thromboembolism or structural degeneration requiring operation. Thromboembolism
occurred in 55 patients (35 permanent, 20 transient) with an actuarial 15-year
freedom in the 861 patients having aortic valve replacement +/- CABG surgery of
92% and in the 105 patients having additional mitral valve surgery of 75% (p =
0.000). Freedom from reoperation from all causes was 50% at 20 years and was
independent of valve preservation. Freedom from reoperation for structural
deterioration was very patient age-dependent. For all cryopreserved valves, at
15 years, the freedom was 47% (0-20-year-old patients at operation), 85% (21-40
years), 81% (41-60 years) and 94% (>60 years%). Root replacement versus
subcoronary implantation reduced the technical causes for reoperation and
re-replacement (p = 0.0098).
CONCLUSION: This largest, longest and most complete
follow up demonstrates the excellent advantages of the homograft aortic valve
for the treatment of acute endocarditis and for use in the 20+ year-old patient.
However, young patients (< or = 20 years) experienced only a 47% freedom from
reoperation from structural degeneration at 10 years such that alternative valve
devices are indicated in this age group. The overall position of the homograft
in relationship to other devices is presented.
PMID: 11380096 [PubMed - indexed for MEDLINE]
