Lancet: Autograft root trumps homograft replacement for aortic valve disease

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Autograft aortic root replacement (a.k.a. the Ross procedure) may have more of a clinical benefit and improve outcomes in patients with aortic valve disease compared with homograft aortic root replacement, according to results of a study published in the August 3 edition of the Lancet.

“The ideal substitute for aortic valve replacement in patients with aortic valve disease is not known,” the authors wrote. While surgery is currently the only effective solution for the disease, survival rates are still low and are dependent on the aortic valve substitute used.

To make data more robust, Ismail El-Hamamsy, MD, of the Royal Brompton and Harefield NHS Trust in London, and colleagues worked to compare the Ross procedure and homograft aortic root replacement to identify the best procedure to increase long-term outcomes.

The researchers identified 228 patients who presented at Royal Brompton and Harefield NHS Trust with aortic valve disease between 1994 and 2001, and randomized the patients at a 1:1 ratio to undergo either a Ross procedure (108 patients) or a homograft aortic root procedure (108 patients). Twelve patients were excluded.

For patients in the study, all underwent a total aortic root replacement and had a mean clinical follow-up of 10.2 years. The researchers performed echocardiogram exams every two years and evaluated the patients’ quality of life post-replacement.

While the researchers found that patients in the homograft group had a higher rate of mortality, they said that the rate did not have statistical significance—3 percent versus 1 percent.

Additionally, the cumulative number of deaths that occurred in the autograft arm one, five, 10 and 13 years after the procedure was three, three, three and four, respectively. Rates of survival were higher in the autograft group compared to the homograft group, the researchers found.

When comparing the two arms of the study, the researchers found that one early and three late deaths occurred in the autograft group and three early deaths and 12 late deaths in the homograft arm.

Hamamsy et al found that patients in the homograft arm had a higher need for aortic valve reoperations one-year, five years, 10 years and 13 years post-surgery compared to those in the autograft group.

These rates of patients in the homograft group were one, two, 16 and 27, respectively. Two patients in the autograft group underwent reoperation 10 and 13 years after surgery.

Patients in the autograft arm had no cases of aortic endocarditis, but did have two cases of pulmonary homograft endocarditis.

Meanwhile, freedom from endocarditis was 98 percent at 10 years and 97 percent at 13 years in the autograft group, compared to 94 percent at 10 years and 82 percent at 13 years in the homograft group.

“The Ross procedure, compared with homograft aortic root replacement, improved survival in adults, and was associated with improved freedom from reoperation and quality of life,” the authors wrote. “The proportion of patients who survived after the Ross operation was similar to that in the general population.”

Additionally, the authors said that “the Ross procedure is the only operation with which long-term viability of the aortic root is guaranteed, which could explain the enhanced survival in the study.”

The researchers concluded that the implementation of a living valve in the aortic position can improve long-term clinical outcomes for patients.

In an accompanying editorial, Salvatore Lentini, MD, of the Policlinico Universitario G Martino in Messina, Italy, wrote, "The ideal valve should have a long life, reducing or eliminating the need for further surgery.”

Additionally, he said that while results seemed better for the autograft patients arm, “autograft is not completely accepted by the surgical community because another portion of the heart is compromised by use of the right side to prepare the pulmonary autograft, and because the compete root is replaced in isolated aortic valve disease.”

Therefore, Lentini concluded that “a more physiological approach during aortic valve and aortic root surgery should be regarded as important for long-term results in patients with aortic valve replacement.”