813-1 The Pulmonary Autograft for Aortic Valve Replacement — Results at 26 Years

Abstract

The fate of aortic valve replacement by pulmonary autograft was studied by follow-up of 131 consecutive hospital survivors from the pioneering centre, the National Heart Hospital. Preoperatively, study patients were 82% male, aged 11–52 yrs and showed the full spectrum of aortic valve disease. Operations were between 1967–1985 and outcome was determined at 1993 (mean 21 yrs follow-up) by retrospective analysis of case notes and outpatient assessment of survivors (including transthoracic echocardiography). Follow-up was 95% complete — only 6 patients were lost. 53 pts died. Actuarial survival at 10, 20 and 25 years was 86%, 59% and 53% respectively. Amongst young patients after the learning curve survival was 92%, 80% and 76% respectively. 46 pts required reoperation — 35 on the “aortic” position (83% for autograft regurgitation) and 31 on the “pulmonary” position (76% for stenosis). Autograft regurgitation was the main indication for reoperation in 29 pts: in 22 regurgitation occurred early and progressed, but in 7 it appeared late. Reoperative findings showed malposition in early failure and degenerative changes (cusp perforation and stretchingl in late failure. Histological analysis of autografts removed up to 22 yrs after insertion consistently revealed viable cells and minimal valvar calcification. Freedom from death and reoperation was 73%, 45% and 35% at 10, 20 and 25 yrs. Pts were not anticoagulated, only one possibly valve related thromboembolic event was found. There were only 3 definite episodes of endocarditis on the autograft. The 72 survivors had average NYHA of 1.2. 58 survivors retained their autograft and 59 their original “pulmonary” position valve replacement. By echocardiography 46/59 autografts showed normal haemodynamics. Only 13 autografts showed significant dysfunction, invariably regurgitation. 29 of the surviving “pulmonary” position valves were malfunctioning, usually stenotic. Excellent long term results when correctly positioned. Little or no degeneration of the autograft and only 22% need replacement of “pulmonary” position homografts over 21 yrs.