The homograft aortic valve: A 29-year, 99.3% follow up of 1,022 valve replacements

Background and aim of the study: The study aim was to elucidate the advanta ges and limitations of the homograft aortic valve for aortic valve replacem ent 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 degreesC stored (124 grafts); thereafter, all homografts were cryopreserved under a rigid protocol with only minor variations over t he subsequent 23 years. Concomitant surgery (25%) was primarily coronary ar tery 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 513), 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 tw o 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 medical ly cured of their endocarditis. Preservation methods ( 4 degreesC or cryopr eservation) and implantation techniques displayed no difference in the over all actuarial 20-year incidence of late survival endocarditis, thromboembol ism or structural degeneration requiring operation. Thromboembolism occurre d in 55 patients (35 permanent, 20 transient) with an actuarial 15-year fre edom in the 861 patients having aortic valve replacement +/- CABG surgery o f 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 str uctural deterioration was very patient age-dependent. For all cryopreserved valves, at 15 years, the freedom was 47% (0-20-year-old patients at operat ion), 85% (21-40 years), 81% (41-60 years) and 94% (> 60 years). Root repla cement versus subcoronary implantation reduced the technical causes for reo peration 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 (less than or equal to 20 years) experienced only a 47% freedom f rom reoperation from structural degeneration at 10 years such that alternat ive valve devices are indicated in this age group. The overall position of the homograft in relationship to other devices is presented.