PULMONARY AUTOGRAFT VERSUS HOMOGRAFT REPLACEMENT OF THE AORTIC-VALVE - A PROSPECTIVE RANDOMIZED TRIAL

Background: Pulmonary autografts offer many theoretical advantages, Ho wever, the operation is complex, may interfere with right ventricular and pulmonary outflow function, and requires a longer operative time t han does the homograft operation, The effects of these potential disad vantages are unknown. Methods: To clarify these issues we randomized 7 0 patients undergoing aortic valve replacement to an aortic homograft group (group A = 37 patients; 53%; 34 male, 3 female) or a pulmonary a utograft group (group B = 33 patients; 47%; 28 male, 5 female), Ages v aried from 12 to 65 years (mean 39 +/- 15 years) for group A and from 3 to 54 years (mean 29 +/- 15 years) for group B (p = not significant) , Eleven patients in group A (30%) and eight in group B (24%) had prev ious aortic valve surgery, All patients were operated on by the same s urgeon, The mean cardiopulmonary bypass time was 113 +/- 29 minutes (r ange 66 to 175 minutes) for group A and 151 +/- 31 minutes (range 115 to 226 minutes) for group B (p < 0.002). Mean aortic crossclamp time w as 85 +/- 19 minutes (range 45 to 140 minutes) for group A and 109 +/- 20 minutes (range 74 to 164 minutes) for group B (p = 0.02), In 32 pa tients (86.5%) the aortic homograft was implanted as a root with coron ary reimplantation, All pulmonary autografts were implanted as a root, Results: No early or late deaths had occurred in this series at a mea n follow-up time of 16 months (range 3 to 21 months), Two patients (on e in each group) required reexploration for bleeding, No statistically significant differences were observed between the two groups with reg ard to ventilatory support (group A, mean 10 +/- 8.5 hours; group B, m ean 29 +/- 85 hours), total blood loss (group A, mean 471 +/- 347 ml; group B, mean 543 +/- 404 ml), intensive care unit stay (group A, mean 1.2 +/- 0.6 days; group B, mean 2 +/- 3.7 days), and hospital stay (g roup A, mean 9.5 = 3.2 days; group B, mean 12 +/- 6 days), Postoperati vely, all patients are in New York Heart Association class I (93%) or II (7%) (p = not significant), Ejection fraction for the two groups di d not change significantly over the follow-up period, Left ventricular mass and diastolic diameter showed progressive regression, with no ap parent difference between the two treatment groups to date, Echocardio graphic evaluation of aortic valve function at 6 months showed good va lve function in all patients with no evidence of aortic regurgitation in 80% of both groups. In group B the right ventricular outflow gradie nt was below 15 mm Hg over the follow-up period. Holter monitoring, av ailable only in 44 patients (63%), showed most of the arrhythmias to b e grade 0 to 1 of the modified Lown grading system. Conclusion: Althou gh the pulmonary autograft requires a significantly longer operating t ime, this does not seem to affect early and medium-term outcome when c ompared with results obtained with aortic homografts, Continued patien t evaluation is warranted, particularly with regard to evidence of val ve degeneration and right ventricular function and arrhythmias in the long term.